Application For APA Membership

Last Name
First Name
Middle Initial
Nickname
Title (Mr., Mrs., Dr.)
Designation P.D.    Ph.D.    Pharm.D.    Technician   
Other
Affiliation (pharmacy, hospital name, etc.)
Address Line 1
Address Line 2
City
State Zip
Phone
Fax
Email Address
License No.
Other License
Graduation Year
Membership Pharmacist in Charge and Store Dues
        Business owner
        Staff pharmacist in charge
        USA Drug
$190.00 Annually Per Store
  Individual Pharmacist Member
$95.00 Annually
  Hospital Pharmacist Member
$115.00 Annually (Includes membership in the APA and AAHP Academy)
  Associate Member
$95.00 Annually
  Retired Pharmacist Member
$10.00 Annually (Over 65 and retired)
  Out of State Pharmacist Member
$60.00 Annually
  Sustaining Member
$300.00 Annually
        Company Name
  Retail Technician
$30.00 Annually
  Student
$5.00 Annually
  Academy of Consultant Pharmacist Member
$20.00 Annually (in addition to APA dues)
  Academy of Compounding Pharmacist Member
$20.00 Annually (in addition to APA dues)
  Academy of Hospital Pharmacist Member (AAHP)
$20.00 Annually (in addition to APA dues)
APA Foundation Sustaining Member........................................................................ $50.00
(Contributions to the APA Foundation are deductible as charitable contributions for federal income tax purposes
to the extent provided by law.)
AP-PAC Contribution.................$100.00     $50.00     $25.00     Other
(AP-PAC deductible on Arkansas State income tax only.)
Tax Deductible Membership dues include APA Journal subscriptions and newsletters.
PAYMENT METHOD  
  Check Payable to APA - Check Number
  American Express   MasterCard   Visa
Name on Card
Card Number
Expiration Date