To download an application form: pdf
Membership Application
International Pharmacist Graduate Association in the United States
(IPHARM-US)
P.O. Box 5031
Bellevue, WA 98009-5031
Email: ipharm_us@yahoo.com, ipharm.us@gmail.com
EE Number (Copy of NABP Correspondence required) _______________
Legal Name: To avoid confusion, use your full legal name whenever you contact Association.
Last___________________________________________
First _____________________________________
Other Name(s): If your name has changed, indicate your former full name(s).
Last____________________________________________
First _____________________________________ Middle______________________
Last____________________________________
First ________________________Middle______________________
Preferred Name (Nickname) _________________________________________
Sex a. Male b. Female
Date of Birth (Optional) _______________________
Mailing Address_____________________________________________________
Number and Street___________________________________________________
City State/Province/Territory Zip or Postal Code_________________________
________________________________________Country______________________
Telephone_______________________________________________
Permanent Foreign Address (required of all applicants)_
____________________________________________________________
Number and Street_____________________________________________________
City State/Province/Territory Zip or Postal Code___________________________
_________________________________________________Country___________________
Telephone _______________________________________________
Cell (Mobile) or Alternate Telephone _____________________________________
Email 1. ____________________________2._________________________________
City and country of birth _________________________
What is your country of citizenship? SPECIFY COUNTRY________________________
What is your country of permanent residence? SPECIFY COUNTRY_________________
Education
Colleges/Universities
1. Name of School__________________________________________________
Location (City, State, Country if other than U.S.)_______________________________
Dates of Attendance (mm /yyyy to mm /yyyy ) _________________________________
Language of instruction_____________________Degree__________________________
2. Name of School__________________________________________________
Location (City, State, Country if other than U.S.)_______________________________
Dates of Attendance (mm /yyyy to mm /yyyy ) __________________________________
Language of instruction_______________________Degree_________________________
Other Educational Programs (Advanced Degree(s))
3. Name of School_________________________________________________________
Location (City, State, Country if other than U.S.)_______________________________
Dates of Attendance (mm /yyyy to mm /yyyy ) __________________________________
Language of instruction _______________________Degree __________________________
4. Name of School___________________________________________________________
Location (City , State , Country if other than U.S.)__________________________________
Dates of Attendance (mm /yyyy to mm /yyyy ) ____________________________________
Language of instruction ________________________ Degree___________________
Current Employer ____________________Title_________________________________
Location_________________________________________________________________
Number of years of experience___________________________________
Career Interest a. Retailer b. Hospital c. Higher Education d. Research
E. Other___________________
Hobbies _________________________________________________________________
What do you expect from joining association?
________________________________________________________________________
___________________________________________________________________
In signing this form, I certify that the statements I have made in this application are true to the best of my knowledge.
Applicant Name (Print) __________________________________________
Signature of Applicant __________________________________Date ______________
Have a nice day!