Join IPhA today and let
The Voice for Pharmacy in Illinois 
work for you!
This form is for use for NEW MEMBERS ONLY.
Do not use to renew your current membership.
(Current members must log in and renew using your member tools.)

Also, remember... not all fields are required. However, the more thorough
you are in filling out this form, the better we can represent and serve you!

Home
 
* First Name: 
     MI:     * Last Name:
    Credentials: 
 ex: R.Ph., FAFSA
NABP ID: 
   DOB (MMDD):
* Street Address: 
* City: 
   * State:     * Zip + 4:  
* Home Phone: 
Home Fax: 
* Home Email: 


Business/Organization
 
Bus/Org Name: 
Title/Position: 
Street Address: 
City: 
       State:       Zip + 4:  
Bus/Org Phone: 
Bus/Org Fax: 
Bus/Org Email: 
   
Who can we thank for referring you to IPhA?


Preferred Contact Address
 
Postal Mail:
Home Bus/Org		 Email:
Home Bus/Org		 Fax:
Home Bus/Org


Primary Pharmacy Practice Setting

   * One Practice Setting selection required.

Chain
Hospital
Student
Clinical
Independent
Technician
Community
Long-term Care
University
Compounding
Management Council LTC
Other
Government
Pharmacological
 
Home Health Care
Retired


Qualificiations
 
College/University: 
Degree: 
Year graduate(d): 
     
* Needed to grant student or new practitioner membership rates. 
If unsure of the exact day, please enter a 1.

License #:     State: 


Membership Type

   * One selection required
Regular Pharmacist Member
$250.00
Associate Member (non-pharmacist)
$250.00
Corporate Member (non-pharmacist)
$650.00
Joint Member (spouse of regular member)
$100.00
New Pharmacist Practitioner 1 (within 1 year of graduation)
$50.00
New Pharmacist Practitioner 2 (within 2 years of graduation)
$100.00
New Pharmacist Practitioner 3 (within 3 years of graduation)
$150.00
New Pharmacist Practitioner 4 (within 4 years of graduation)
$200.00
Out-of-State Pharmacist Member
$100.00
Retired Pharmacist Member
$100.00
Student Member
$  10.00
Technician Member
$  40.00
   
I am interested in possibly serving on an
     IPhA committee. Please contact me. 		 

What Piqued Your Interest in Becoming a Member?
 
Received an "All In" Poker Chip IPhA Presentation at a
     Local Association Meeting
Received a Renewal Notice IPhA Presentation at my
     College of Pharmacy
An IPhA Certificate Program Following IPhA via Facebook/Twitter
The Illinois Pharmacist Publication The Annual Meeting/CE Program
Friend/Colleague Referrral The IPhA Website (www.ipha.org)

For federal income tax purposes, membership dues may be deductible in part as ordinary
and necessary business expenses. IPhA reasonably estimates that 23% of the dues are
not deductible because of lobbying activity.  Dues or similar payments are not
deductible as charitable contributions.