Idaho State Pharmacy Association

P.O. Box 140117 * Boise, Idaho 83714-0117

208-424-1107 Fax: 208-376-3131

[email protected]

Membership Application

 

First Name_____________________Last Name______________________________

Address______________________________________________________________

City_______________________________State________Zip Code_______________

Home Phone: _____________Work Phone: ________________ Fax: _____________

E-Mail Address: _______________________________________________________

Place of Employment: __________________________________________________

ISPA MEMBERSHIP DUES: Membership is valid for one year from receipt of payment.

(Please check appropriate category)

____ Active $158.00

____ Part-Time Pharmacist $100.00 (Less than 20 hrs. per wk.)

____ 1st Year Member $ 79.00

____ 1st Year Pharmacist $ 53.00 ____ 2nd Year Pharmacist $106.00 ____ Associate $158.00

____ Faculty $ 53.00

____ Retired $ 42.00

___ Student $ 11.00 ___ Professional Year

____ Sustaining $350.00

____ Technician $ 26.00

Enclosed is my check in the amount of $ ___________. I prefer the 3-pay option. [ ]

I wish to charge my 2004/2005 dues to my Visa/Mastercard - Exp. Date _____________

Account ________________________________________________________________

Signed:_________________________________________________________________

 

 

ISPA – Serving the Profession Since 1907