OWRA Membership Form   

Print, fill out, and mail with $10 dues payment to:

Jennifer Taylor, Membership Chair, 4949 Tealtown Rd., Milford, OH 45150

Name ________________________________________________

Address ______________________________________________

City ___________________________________________________

County _____________________________ Zip ______________

Home phone __________________________________________

Work phone ___________________________________________

Rehabilitation organizations, please fill in appropriate permit numbers

USF&WS permit # ________________________

Ohio permit # ___________________________

Membership Category, please check one

[  ] Individual or Family, $10

[  ] Rehabilitation Organization, $10

[  ] Supporting Organization, $10

Directory Information, complete all that apply

[  ] I am authorized to accept wildlife for rehabilitation

I hold permits for [  ] State of Ohio [  ] USF&WS

[  ] I am authorized by ________________________________________ (permit holder) to accept wildlife

[  ] I do NOT want my phone number listed in the directory

Areas of expertise or species experience I am willing to share  _________________________________________________

 ________________________________________________________________________________________________________________________

Other rehabilitation organization affiliations ______________________________________________________________________

_________________________________________________________________________________________________________________________