Join the Philadelphia Association Of Retail Druggists * Membership Invoice / Application to become a Member of PARD Fill in the form,. Please provide all information. To make it easier to read, this isa two page document. Fax this application to : 215 - 464 - 9895

Your Name __________________________________________________________ Name of Pharmacy ____________________________________________________ Is this application a renewal ? Yes No Are you a licensed Pharmacist ? Yes No Your Email Address Address Line One Mailing Address Pharmacy City Pharmacy State Pharmacy Zip Code Pharmacy Phone Pharmacy Fax County Assocation Graduated Month / Year School PA Pharmacist License Number Pharmacy License Number NABP Number DEA# Number MEMBERSHIP CATEGORIES - check one 1. Category A / Active Store Owner In Philadelphia: (Voting Membership) $275.00 2. Category B / Multi Store Owner/In Phila: 2nd Store (Voting Membership) ** $275.00 3. Category C / Active Store Owner Outside Phila: (Voting Membership) $275.00 4. Category D / Multi Store Owner/Outside Phila: 2nd Store(Voting Membership) ** $275.00 5. Category E / Associate Member, i.e., licensed pharmacist * $75.00 6. Category F / Retiree (R. Ph. or Non R. Ph.) * $60.00 8. Category H / Manufacturer Or Wholesaler * $100.00 9. Category I / Corporate or Organizational * $500.00 *Indicates Non Voting Status ** Not to exceed a total of 3 votes Card Holder Name _____________________________________________________________ Credit Card Type VISA MASTER CARD Credit Card Number _____________________________________________________________ Expiration Date Month ____________________ Year ________________________ Is the billing zip code the same as above ? YES NO (if NO, enter the credit card billing zip code) _____________________________________________________________ Fax this application to : 215 - 464 - 9895