Membership Application

Pediatric Pharmacy Association
Membership Application Form

*Denotes required field

Account Lookup / Create New Account

Click the Account Lookup button to the left.
Enter the search criteria and click Continue.
If you see your name, please press the Choose button next to your name.
If you do not see your name, click the Create an Account link.

To join via mail or fax, please download the Membership Form (PDF).

Step 1: Member Information

Prefix:
* First Name:
Middle Name:
* Last Name:
Suffix:
* Work Address:

* City:
* State/Province:
* Zip:
* Phone:
Please enter phone number in the format: 555-555-5555
Fax:
Please enter fax number in the format: 555-555-5555
* Email Address:
* Home Address:

* City:
* State/Province:
* Zip:

Step 2: Professional Practice Information

Member Recruiter:
* Company/Institution:
Position Title:
NABP Number:
Board Certifications:
Other Certifications:
* DOB:
* Practice Start Date:
Primary Practice Areas:
Other Practice Areas:
Student Groups:
Local Groups:

* Step 3: Membership Category

$250.00	Individual	For pharmacists committed to the goals of PPA and actively involved in (or has substantial experience in) pediatric pharmacy practice.
$250.00	Associate	For non-pharmacists committed to the goals of PPA (MD, RN, FNP, PhD).
$70.00	Resident/Fellow	For pharmacists in a residency or fellowship program.
$60.00	Pharmacy Technician	For pharmacy technicians committed to the goals of PPA.
$45.00	Student	For pharmacy students enrolled in a school or college of pharmacy.

Pediatric Pharmacy AssociationMembership Application Form

Pediatric Pharmacy Association
Membership Application Form