Ohio Lactation Consultant Association

Membership Application

Name: ____________________________________Title (eg: IBCLC, RD/LD, RN, LLLL)____________________

Place of Employment:__________________________________________________________________________

Preferred Mailing Address:______________________________________________________________________

City: __________________________________County: ____________________State:_____ Zip: _____________

Home Phone: __________________________________Work Phone: ___________________________________

Fax Phone: ____________________________Email Address: __________________________________________

_______ Enclosed is my $25.00 check to O.L.C.A. for membership*

________ Address change only

____ Do not include my name on mailing lists provided to external organizations.

Mail to: Pat Bucknell, IBCLC
OLCA Membership Chair
204 James Circle
Avon Lake, OH 44012

*OLCA is a 501C(6) Corporation and membership may be deductible. Check with your tax advisor