Pharmacy Student Membership Application

First Name

Last Name

Email

Username

Password

Phone Number

Home Address

City

State/Province

Postal Code

Country

Email Address

Cell Phone

Home Telephone
*Pre-Pharmacy College Attended:

*Pre-Pharmacy College Date:
*Pre-Pharmacy College Attended: 1

*Pre-Pharmacy College Date: 1
*Pharmacy College in which presently enrolled.
*Degree Expected: B.S. in Pharmacy in: (Month/Year)
*Doctor of Pharmacy in: (Month/Year)
*List pharmacy related associations in which you hold membership. (Include offices held and committee work.)
*List positions held by you as a pharmacy intern. (Include dates and location.)

*List pharmaceutical and medical journals that you read regularly.

*Three (3) personal references, e.g., faculty, previous employers:

Student Membership Information

*Upon graduation, do you plan to practice in a pharmacy owned by others, or to establish your own practice?

*If employed by others, do you plan to practice in:



*In which state(s) do you intend to practice or seek licensure, upon graduation?

*If you were you referred by an ACA Member to join, please provide their name here. If not, enter NA.

*How did you learn about membership in the ACA?

*PLEDGE: I hereby pledge myself, as a condition of Membership in the College, to comply with the requirements for Membership; all its principles, declarations and regulations, as now written or as hereafter may be amended, in the Constitution and Bylaws of the American College of Apothecaries.

Signature


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