Maryland Pharmaceutical Society

Representing Minority Pharmacists in Maryland

Membership Form

Membership Year 200___

   

Title:     Name:

Home Address:

Home Address 2:

State:     Zip:

Home Phone:        Work Phone:          Fax:

E-mail:

Employer:

Membership Fee    New/Renewal Fee $125.00    Pharmacy Technician/Affiliate Fee $50.00    

                                    New Graduate -- Free

Make check payable to: Maryland Pharmaceutical Society Mail completed form to: Maryland Pharmaceutical Society PO Box 1182, Owings Mills, MD 21117 Federal Tax ID Number: 23-72166256625