Addiction Day Registration

OPA Addiction 101 Day 2019 Conference

Saturday, September 28, 2019
LI KA SHING KNOWLEDGE INSTITUTE at St.Michael's Hospital
209 Victoria Street, Toronto, Ontario

Space will fill up quickly so book early to avoid disappointment!

All fields marked with an asterisk (*) are required

Contact Information

First name: *
Last name: *
Institutional Affiliation:
Address: *
Suite #:
City: *
Province/State: *
Country:
Postal/Zip Code: *
Email: *
Phone: *
Fax:
Website:

Privacy Policy for Conferences

Personal information collected on this form will only be used for purposes of conference administration.

I consent to have my information used to provide me with OPA communications.

Yes No

Fees Selection

Full Conference (includes breakfast, luncheon & refreshment breaks.) *

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OPA Member - Full: $

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OPA Member Associate/Life/Inactive/ Honorary: $

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OPA Member - Resident: $

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Non Members – Physicians: $

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Payment Information

Subtotal:	0.00
Tax (13% HST) HST #899667364 RT0001:	0.00
Total:	0.00
Name on Card: *
Credit Card Number: *
Expiration (MM/YYYY): *	/
CVC: *

First Name*
Last Name*
Company*
Email:*
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