Please print out this page, complete it, and return by fax to (760) 875-7709 (credit card payments only please) or mail to:

San Diego County Pharmacist Association
6549 Mission Gorge Road; PMB #101
San Diego, CA. 92120
 

Date: ____ / ____ / ____                   CA Lic # ____________

(Check one) Mr. ___ Mrs. ___ Ms. ___ Dr. ___ Other _________________

Name: _____________________________________________________

Home Address: ______________________________________________

City, State, Zip: _______________________________________________

Home Phone: (____)_____________

Home Fax Number: (____)_____________ Home E-mail address: ___________________

Work Address: ______________________________________________

City, State, Zip: _______________________________________________

Work Phone: (____)______________

Work Fax Number: (____)_____________ Work E-mail address: ___________________

Preferred Mailing Address (check one): Work ____ Home ____

Preferred delivery of Insights:  FAX  ____ E-mail  ____  Mail  ____

Pharmacy School _____________

Highest Degree (check one): B.S. ____ Pharm.D. ____ M.S. ____ Ph.D. ____

Graduation Date for Highest Degree: ____ / ____ / ____

Referred By:_______________________________ (www.sdcpha.com website application)

Membership Selection

____ Pharmacist Member … $390.00

____ Associate (non-pharmacist/sales reps.) … $125.00

____ Associate with optional Local … $150.00

____ Pharmacy Technician … $100.00

____ Pharmacy Technician with Local … $125.00

____ 1^st year graduate pharmacist … $125.00

____ 2^nd graduate pharmacist … $250.00

____ Pharmacy Resident … $65.00

1 FREE Academy Membership: Please designate which academy you wish to be placed in. (Pharmacists only)

____ Pharmacy Owners

____ Employee Pharmacists  (subselections: ____ Manager or ____ Staff)

____ Long Term Care

____ Hospital Pharmacists

____ Pharmacy Students

____ Pharmacy Specialties
(subselections: ____ Academician, ____ Correctional Facilities, ____ Government, ____ Industry, ____ infusion care, ____ managed care, ____ Nuclear Pharmacist, ____ Other)

$25 for each additional academy added.

What is your local association? San Diego County Pharmacists Association

How did you hear about the San Diego County Pharmacists Association? (please choose from list below)

__ San Diego County Pharmacists Association member  (name ____________)
__ SDCPhA website (www.sdcpha.com)
__ web search
__ word of mouth
__ other  ______________

Method of Payment:

____ I would like my annual dues deducted from my checking account on a monthly basis and I have attached a voided check.  (note:  Your yearly renewal amount will be divided into 12 equal monthly payments.)

____ I would like to pay my membership dues in one payment

____ Check made payable to CPhA for $___________

____ Charge $___________ to my (check one): ___ VISA ___ Mastercard

(Card Number ___________________________ Exp. Date ____ / ____)

Signature ________________________Date ___________________________

Note:

CPhA dues are not deductible as a charitable contribution for tax purposes. Effective January 1, 1994, the IRS will not allow a deduction for the 14% of your CPhA dues spent for lobbying purposes. The remainder of your CPhA dues may be deductible as a business expense. Please consult your accountant for more information.
Questions? call the Membership Division at (800) 444-3851 (CA Only) or (916) 444-7811