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.

Save 25% off 2023 Membership Dues!! Join Now!

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 * +

Ethnic Origin *

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.