You may be eligible to receive a promotional plaque at no charge to you. As long as you are a member in good standing in the OPBA for over twenty-four (24) consecutive months at the time of your promotion.  Request must be made within six (6) months of said promotion to receive benefit.  Please complete the areas below.

First Name:
Middle Initial:
Last Name:
Mailing Address:
Phone Number:
Email:
Position Promoted To:
Department:
Promotion Date:
	Enter the text shown in the image above.