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| 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
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Zip
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| Phone / ext. |
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Nickname
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| Email |
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Birth Date (mm/dd/yyyy) |
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| Cell Phone |
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Expected Graduation Date (mm/dd/yyyy) |
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| College |
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Are you trained to provide immunizations?
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| School Information |
| Address at School
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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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| 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 |
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| IPF Contribution* $ |
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If Other Selected
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*Contributions to IPF is 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 |
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Senate
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