* Only boxes marked with an * asterisk are required fields. All other fields are optional but will help us maximize the benefits of your membership experience.

STUDENT PHARMACIST MEMBERSHIP ONLINE APPLICATION

Name*

Suffix ( Jr., III, IV, etc.)

Preferred Salutation (Mr., Mrs., Miss., Dr., Ms.)

Nick Name

Sex Male   Female
Date of Birth (format mm/dd/yyyy)
   
Name of Spouse - if applicable

Home Address*

City*

State*

Zip Code*

County*

Home Phone with area code

Home Fax - if applicable

Cell Phone with area code

School Name*

School Address - used during the year - if different

City

State

Zip Code

School Phone with area code

School Fax

Intended month & year of graduation*

 

Home e-mail address

School e-mail address

Preferred Mailing Address*
Home  School
Preferred E-Mail Address*
Home  School

Recruited By:

By providing the above fax number(s) and email addresses, I hereby am providing my informed and written consent to receive by fax and/or 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

Type Initials Here       Date

**Students are automatically enrolled in the Academy of Student Pharmacists

Dues Amount Remittance
Student Pharmacist  (Non-Voting Membership) - $15.00 / *One School Year

Dues are based from Sept 1 through August 30. / *Joining in the summer will count towards the upcoming school year

Renewal dues are typically billed approximately 30 days before due date, with one reminder about 10 days out.  Members with unpaid dues after the September 30 of each year are considered inactive.

*Contribution or gifts to the Pennsylvania Pharmacists Association are not deductible as charitable contributions for federal income tax purposes. However, such payments may be deductible as business expenses or other provisions of the Internal Revenue Code.  The Internal Revenue Service requires notification of the allocation of lobbying expense included in total membership dues which is not deductible. This amount is 5% of dues. Please consult with your accountant or tax attorney on these matters.