PPA - Online Form

The Pennsylvania Pharmacists Association is a professional membership society of registered pharmacists, certified pharmacy technicians, and pharmacy students who reside, work, attend college, or are interested in pharmacy in the Commonwealth of Pennsylvania.

CURRENT ISSUES &
UPCOMING EVENTS

Pennsylvania Pharmacists Association
STUDENT DATA INFORMATION FORM

Name

Nickname

Social Security Number

School

Intended Month / Year of Graduation

Sex:
Male Female

Home Street Address

Home City - State - Zip Address

Home Address COUNTY

Home Phone Number

School Street Address

School City - State - Zip Address

School Phone Number

Cell Phone Number

Preferred Mailing Address
Home School

Primary Email Address

Secondary Email Address

Multi Year Membership Program - Student membership is $15.00 a year - however you may opt into our special multi-year discounted program.

**Please note – this program is optional, you may continue to pay $15 each year. The program works this way, based on the number of years you have remaining in pharmacy school, you may pay for multiple years and in doing so receive a discount. You will not receive a renewal notice in these subsequent years, because you are paid up through to your graduation! Please check which option you prefer, your credit card will be charged this amount.

Number of Additional Student Years	Amount To Pay	Savings
1 year	$15.00	----
2 Years	$25.00	$5.00
3 Years	$35.00	$10.00
4 Years	$45.00	$15.00
5/6 Years	$50.00	$25.00

By providing the above email addresses, I hereby am providing my informed and written consent to receive by email any and all communications from the Pennsylvania Pharmacists Association and any of its subsidiary and affiliated organizations and entities. I understand that PPA does not share my fax numbers, home phone, or any email addresses with any other organization or business and only provides mailing addresses pending review and approval of intended mailings.

home || contact us || privacy policy || web site security