NMPhA Membership Application


		NMPhA Membership Application
	Print this form and mail to: *(fax to: 255-8476):*
					New Mexico Pharmacists Association 2716 San Pedro, NE, Suite C Albuqueruqe, New Mexico 87110


	Applicant Information
	Applicant Information				NAME	TITLE
					NAME	TITLE

	ORGANIZATION/COMPANY
					HOME PAGE URL

	MAILING ADDRESS				STREET ADDRESS
							ZIP CODE
	CITY		STATE

					HOME PHONE
	WORK PHONE


	FAX NUMBER				E-MAIL ADDRESS


	Practice Type - Mark all that apply!


		Independent

	Hospital

	Education


	Chain

	HMO/MCO

	Federal


	Supermarket

		Consultant

		Other


	Clinic

	Pharmacist Clinician

		Pharmaceutical Co.


	Are you interested in working on a committee?


	Convention

	Finance


	Legislative

	Education


	Medicaid/Medicare

	Pharmacy Tech.


	Membership

	Public Relations


	*Payment Information*



	Method of Payment				Total Payment

	Name on card				Account Number					Expiration Date


	Membership Dates: Your membership will be based on the month you join. If you join in June your membership will expire at the end of June. With this change the grace period of two months to renew will no longer be in effect


	Who - What - Why - Council - Mission - Application