MPA Membership Application

Michigan Pharmacists Association welcomes you as a member! Please complete and submit the 2011 membership form below to join us in advancing pharmacy in Michigan. By doing so, you receive all membership privileges and subscribe to MPA Code of Ethics.

When joining with a one-year membership, you will receive benefits through Dec. 31, 2012. With a two-year membership, benefits extend through Dec. 31, 2013. Click here to access a printable application.

**PLEASE NOTE: After joining MPA, your membership and web access will not be activated for approximately five business days.  If you need to register for a program or have access to the Web site immediately, please contact MPA at MPA@MichiganPharmacists.org or (517) 484-1466.   

Personal Information
First Name:
Middle Initial:
Last Name:
Birth Date: / /
Credentials:
Sex: Male Female
Address:
City:
State:
Zip Code:
Phone:
Cell:
E-mail Address:
Professional E-mail:

Professional Information
Employer/Business:
Your Title:
Address:
City:
State:
Zip Code:
Phone:
Fax:
E-mail Address:
Website:

Preferred Contact: Home Business
Referred by:

Practice Affiliation
Consultant Pharmacists Society of Michigan
Michigan Society of Community Pharmacists
Michigan Society of Health-System Pharmacists
Michigan Society of Pharmacy Technicians
Student Michigan Pharmacists Association

Professional Qualifications
Pharmacist
College Attended:  
If currently a student, indicate year:  
Degree:  
Pharmacy Technician
Training Received:
CPhT Designation: Yes No
Date of Certification: / /

Membership Type
Active Pharmacist ($276.00 - $525.00)
A pharmacist in active practice
Pharmacist Joint with Spouse ($140.00 - $250.00)
A pharmacist whose spouse is an active full paying member
Limited Practice ($125.00 - $225.00)
A pharmacist who practices pharmacy fewer than 20 hours per week
Retiree ($125.00 - $225.00)
A pharmacist who has retired and no longer practices pharmacy
Academia ($125.00 - $225.00)
A pharmacist who is a full-time faculty member as outlined by the college of pharmacy
Out-of-State Pharmacist ($125.00 - $225.00)
A pharmacist who lives out of state and desires to receive MPA publications and continuing education credits
Student Pharmacist ($10.00)
A student pursuing a pharmacy degree, valid for one year
Student Pharmacist - Career ($25.00)
A student pursuing a pharmacy degree, through completion of pharmacy school
Pharmacist Conversion Step One ($70.00)
A pharmacist who graduated from a school of pharmacy in 2011
Pharmacist Conversion Step Two ($140.00)
A pharmacist who graduated from a school of pharmacy in 2010
Associate ($86.00)
A non-pharmacist who would like to join MPA (includes pharmaceutical representatives)
Pharmacy Technician ($64.00 - $110.00)
A person who works as a pharmacy technician (does not have to be certified)
Pharmacy Technician Student ($10.00)
A person who is enrolled in a school to receive training to become a pharmacy technician

MPA dues are not tax deductible for income tax purposes. However, they may be deductible as ordinary and necessary business expenses, subject to restrictions imposed as a result of organization lobbying activities. MPA estimates that the nondeductible portion of your 2012 dues is 10.45 percent.


Contributions
I would like to make a contribution to the Michigan Pharmacy Political Action Committee (PAC) in the amount of:
$
If you are making a contribution to the Michigan Pharmacy Political Action Committee (PAC) please select whether you will be using a personal or corporate credit card:
  
I would like to make a contribution to the Michigan Pharmacy Foundation in the amount of:
$

Communications
Michigan Pharmacists Association must have your signed, written consent for you to receive faxes or e-mails sent by or on behalf of Michigan Pharmacists Association, Michigan Pharmacy Foundation, Michigan Pharmacy PAC, Consultant Pharmacists Society of Michigan, Michigan Society of Community Pharmacists, Michigan Society of Health-System Pharmacists, Michigan Society of Pharmacy Technicians, Pharmacy Services Inc. and/or PSI Insurance Agency and Well Street Care Management.

By typing your full name in the signature line below, you allow us to send you important MPA and affiliated communications.

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Please support MPA's family of companies:
MPA Family of Companies Michigan Pharmacy Foundation Pharmacy PAC Pharmacy Services Inc. PSI Insurance Agency Well Street Care Management