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**If you are an IPA member, please enter your username and password – this will automatically populate the fields below with your personal information.**
If you are not a member please continue filling out the rest of the form and click the Save button at the bottom of the page.
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| User Name
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Password
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Forgot your password? Click here.
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| Pharmacist Membership Enrollment Form |
| First Name
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Last Name
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| Preferred Mailing Address
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State
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| Home Address
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City
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| Address 2
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Zip
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| Nickname
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Phone / ext. |
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| Email
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Cell Phone |
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| Birth Date (mm/dd/yyyy)
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License #
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| College
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Graduation Date (mm/dd/yyyy)
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| Spouse
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Do not include me in the directory
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| Are you an immunizing pharmacist? |
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Are you PCM trained? |
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| Employment Information |
| Name |
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Work Address |
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| Address 2
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City
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| State
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Zip
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| Phone / ext. |
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Fax
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| Employment Status |
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If Other Selected
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| Primary PracticeType: |
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If Other Selected
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| Other Practice Types: check all that apply |
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If Other Selected |
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| Practice Interests: check all that apply |
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If Other Selected
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| Membership Dues |
Pharmacist - Resident
($105.00) |
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| IPF Contribution* $ |
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If Other Selected
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*Contributions to IPF are optional.
Contributions to the Iowa Pharmacy Foundation (IPF) are tax deductible as a
charitable contribution. Contributions to IPA are not deductible as charitable
contributions. However, dues may be deductible as an ordinary and necessary
business expense. A portion of your dues includes a subscription to the
official publications of the Iowa Pharmacy Association.
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| Legislative Information - Enter District |
Click here for Iowa Senate districts
Click here for Iowa House districts
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| House
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Senate
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| Party |
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