MPA Annual Membership Application

If you would like to join MPA or renew your membership with Michigan Pharmacists Association, please fill out the form below and submit payment.

If you are not sure which membership category to choose, please contact MPA Membership Director Scott Walsh at SWalsh@MichiganPharmacists.org (517) 377-0241.

Is this for an MPA Membership Renewal or a New Membership? *

MPA Membership Renewal

New MPA Membership

Prefix

First Name *

Last Name *

Maiden Name (if applicable)

Spouse Name (if applicable)

Nickname (if applicable)

Gender *

Date of Birth * +

If you have a Canadian address, please call our office to renew

Mailing Address

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

County *

Is your mailing address the same as your billing address? *

Billing Address

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

County *

Employer Name (students enter university attending, retirees enter retired) *

Job Title

Work Street Address

Address Line 2

City

State

Zip Code

Cell Phone Number *

Work Phone Number

Home Phone Number

Educational Institute (if none, put none) *

Date of Graduation *

Primary Practice Section *

Secondary Practice Section (if applicable)

Primary Email Address *

Secondary Email Address

Membership Type (please choose from dropdown below)

*

Promo Code:

Current Total:

$0.00

Click CONTINUE to go to payment processing

Disclosure *

We are not offering auto-renewals at this time. Please note this is a single payment and you will receive a statement prior to your next renewal date. Membership processing time is between 3-5 business days.