Membership Application

Please fill out the form below completely. Or, print off this membership form and fax or mail back to MPA.

If you are renewing your membership, do not use this form. Click here for the Renewal Application.

  Personal Information
Please Select: Mr. Mrs. Ms. Miss Dr.
First Name *
Middle Initial
Last Name *
Birth date
Suffix Pharm.D. R.Ph. CPhT or Other
Gender (optional) Male Female
Address *
City *
State *
Zip *
Telephone *
Cell Phone
E-Mail Address
   
    Business Information
Business Name
Your Title
Business Address
City
State
Zip
Telephone ext
FAX
Business E-mail
Preferred Address Business Home
  Membership Information
Type
PAC Contribution
*If you chose a pharmacist membership category, please choose a practice section.
Consultant Pharmacists Society of Michigan
Michigan Society of Community Pharmacists
Michigan Society of Health-System Pharmacists

***Includes membership in a regional society.
Washtenaw Area Pharmaceutical Representatives Association

Membership Invitation Extended By:

Board of Pharmacy Number

   

School Attended

Year Degreed

Degree
   

School Attended

Year Degreed

Degree
   

School Attended

Year Degreed

Degree

If you chose other for any of the degree choices above, please explain
* Denotes a required field