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| Business Partner Enrollment Form |
| Pharmacy Name
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License #
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| Address
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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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| Email
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Web Address
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Does your pharmacy provide Immunizations?
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| Please check all programs your pharmacy participates in: |
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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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| Membership Dues |
| Business Partner (Pharmacy)
$250.00 |
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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.
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| Included with your Business Parnter Membership is the
current Iowa Pharmacy Law and Information Manual |
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