Membership Renewal Application

 Personal Information
Please Select: Mr. Mrs. Ms. Miss Dr.
Member ID
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

Year Degreed

Degree
   

School

Year Degreed

Degree
   

School

Year Degreed

Degree

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