TEXAS CHAPTER ORTHOPEDIC PHYSICIAN ASSISTANT’S

www.TCOPA.org

 

Please Send Payment to:

TCOPA

c/o  David Bartczak, OPA-C

4519 Ringrose Dr 

Missouri City, TX 77459

 

Need Information email:  dbartczak@houston.rr.com  (preferred)

Cell 832-788-7283

 

 

Name ______________________________________________________________________________________________________      

 

Home Address_________________________________________________City_____________________State_________________

 

Zip Code____________________ Phone  # Home________________________             Mobile_____________________________________  

 

Employer Name__________________________________________  Phone # Work ______________________  Fax___________________

 

Employer Address_________________________________________________City_____________________State_______________

 

Zip Code____________________  Title___________________________________________________________________________

 

Email ________________________________________________ Date of Birth___________________________________________

 

Preferred Method of Contact  ___________________________________________________________________________________

 

Credentials(OPA-C, OTC, SA, RN etc) ___________________________________________________________________________

 

Member of ASOPA              Yes         No         

 

NBCOPA#_________________  Date Certified_____________________  

 

 

TCOPA  Full Membership Dues for 12 Months ----------------$100

 

TCOPA#________________          Publish Contact Information On Member Section of Website      Yes      No

___________________________________________________________________________________________________________

 

Official Use ONLY

 

 

TEXAS CHAPTER OF ORTHOPEDIC PHYSICIAN’S ASSISTANTS

 

 

RECEIPT FOR DUES OF CHARTER MEMBERSHIP RECEIVED

 

AMOUNT PAID $______________

 

NAME_______________________________________________

 

TCOPA#_______________  Website Login and Password ____________________________________________________________

 

NAME OF MEMBER_________________________________________________________________________________________

 

RECEIVED BY_________________________________________        DATE_________________________