Membership Application
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Name
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First Name
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Postal/Zip Code
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Email
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example@example.com
Business Name
Company
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State
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AL
AK
AZ
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
,NM
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
DC
WV
WI
WY
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Business Email
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example@example.com
Current Job Position (Check one):
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Director of Pharmacy
Assistant Director
Pharmacy Manager
Staff Pharmacist
Pharmacy Technician
Clinical Pharmacist
Community Pharmacist
Pharmaceutical Industry
Pharmacy Resident
Academic Faculty
Pharmacy Student
I am interested in the following Committee:
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Administrative Affairs
Corporate Alliance Council
Organizational Affairs
Professional Affairs
Student Affairs
Educational Affairs
Pharmacy Technician Affairs
Nominations Committee
Awards Committee
Sponsoring Member
First Name
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Membership Category
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Active (Pharmacist)
$
150.00
Quantity
1
2
3
4
5
6
7
8
9
10
Associate (Non-voting)
$
150.00
Quantity
1
2
3
4
5
6
7
8
9
10
Pharmacy Resident
$
100.00
Quantity
1
2
3
4
5
6
7
8
9
10
Pharmacy Technician
$
50.00
Quantity
1
2
3
4
5
6
7
8
9
10
Pharmacy Student
$
35.00
Quantity
1
2
3
4
5
6
7
8
9
10
ABHP Foundation Donation
$
35.00
Quantity
1
2
3
4
5
6
7
8
9
10
Payment Methods
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