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!

Personal Information

* First Name: 

     MI:     * Last Name:
Suffix:
ex: Jr., III...       Credentials: ex: R.Ph., FAFSA
* Street Address: 
* City: 
      * State:        * Zip:  
* Phone Number: 
Fax Number: 
Email Address: 

Professional Information

Organization Name: 

Organization Type: 
Job Title: 
Street Address: 
City: 
        State:        Zip:  
Phone Number: 
Fax Number: 
Email Address: 
Business Website: 


Preferred Contact Address

   *       Home    Business



Primary Pharmacy Practice Setting

   *
Independent Chain Compounding
Long-term Care Home Health Care Hospital
Government Agency University Other


Professional Qualificiations

College Attended: 
Degree: 
Year graduate(d): 
     
* Needed to grant student or new practitioner membership rates.
   
License Number: 
State: 


Membership Type

   *
Regular Member
$250.00
Associate Member (non-pharmacist)
$250.00
New Practitioner (within 1 year)
$100.00
Retired Member
$100.00
Student Member (1st professional degree enrollee only)
$  10.00
Technician Member
$  40.00

Out-of-State Member
(Must be more than 50 miles outside of Illinois border to qualify.)
$100.00
Joint Member (spouse of regular member)
$100.00
Corporate Member (non-pharmacist)
$650.00


Contributions

I would like to make a contribution to the Illinois Pharmacists Political Action Committee (IPPAC) in the amount of $ .00

I would like to make a contribution to the IPhA Foundation in the
amount of $ .00

Communications

The Illinois Pharmacists Association must have your signed, written consent if you wish to receive member communications including E-Info Exchange newsletter, PharmPhlash blast notices, meeting reminders, etc. By entering your name in this section prior to submitting this form, you allow us to send information which you request or to which you otherwise may be entitled.

 

 
Signature:
(TYPE FULL NAME)

(PLEASE CLICK SUBMIT ONCE ONLY!)