APSA 2012-2013 MEMBERSHIP APPLICATION
Save yourself some time and hassle. Register for your membership for APSA before you go on rotations!

DEADLINE: April 17, 2012
Please submit your application and checks NO LATER than April 17, 2012. Only members who register by this deadline will be guaranteed a NAPLEX book with their APhA memberships -- NO EXCEPTIONS!

* Dual deluxe membership - APhA/IPSF (2 year membership), CPhA, ASHP, CSHP -- $225
BENEFITS: Free NAPLEX review book with 300 bonus practice questions, APhA 2 year membership includes P4 year and 1 year post-graduation, "New Practitioner" year through October 2014

* Dual standard membership - APhA/IPSF (1 year membership), CPhA, ASHP, CSHP -- $170
BENEFITS: Free NAPLEX review book, plus $10 S&H fee, with 200 bonus practice questions

* Single deluxe APhA/IPSF (2 year membership) & CPhA -- $150
BENEFITS: Free NAPLEX review book with 300 bonus practice questions, APhA 2 year membership includes P4 year and 1 year post-graduation, "New Practitioner" year through October 2014

* Single standard ASHP & CSHP membership -- $100

* Single standard APhA/IPSF (1 year membership) & CPhA membership -- $100
BENEFITS: Free NAPLEX review book, plus $10 S&H fee, with 200 bonus practice questions

Tabling sessions:
April 9, 11-1 PM
April 10, 12-2 PM
April 11: 11-1 PM
April 12, 11-1 PM
April 16: 11-1 PM
April 17: 11-1 PM

Please submit checks made out to "APSA" to Bonny Chan, Andrew Warnock, Lydia Noh, Nina Bolour, Gordon Chau or Meagan Toy. Send all questions to apsamembership@gmail.com
* Required
Sign in to Google to save your progress. Learn more
The Basics
Please complete the following information completely and carefully. This information will be used to register you for each of the parent organizations (APhA/IPSF, CPhA, ASHP, CSHP).
First Name *
Last Name *
Middle Initial
USC Email *
Personal Email *
Non USC Account
Phone Number *
222-333-444
USC Student ID *
2222222222
Ca Intern License Number
Month of Birth *
Day of Birth *
Year of Birth *
Local Mailing Address - Number, Street, Apt Number *
1985 Zonal Ave, #202
Local Mailing Address - City, State *
Los Angeles, CA
Local Mailing Address - Zip Code *
91803
Permanent Mailing Address - Number, Street, Apt Number
1985 Zonal Ave, #202
Permanent Mailing Address - City, State
Los Angeles, CA
Permanent Mailing Address - Zip Code
90089
Has Your Address Changed from last year *
Required
Preferred Mailing Address *
This is the address that will be used to register you with the parent organizations.
Part 2. Parent organizations and membership dues
Please select the memberships are you registering for. *
Note: APhA 2 year membership includes P4 and New Practitioner membership through October 2014
Required
Thank You
Congratulations, Your application is now complete. Please submit your dues to an APSA board member tabling in the lobby. If you have any questions, comments or concerns, please contact Gordon Chau at APSAmembership@gmail.com or at 773-844-8950


Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms