| 1. Personal Data | * Denotes a required field |
|---|
| Prefix: | |
| * First Name: | |
| * Last Name: | |
| : | |
| Highest Degree: | |
| Affiliation: | |
| Department: | |
| Title: | |
| Address: | |
| City: | |
| State or Province: | |
| Postal Code: | |
| Country: |
|
| Telephone: | (With full international codes) |
| Fax: | |
| * Email: | |
| Website: | |
| Language: : | |
|
| 2. Choose Password * |
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| 'Password' must be between 6 and 10 digit long |
| Password: | |
| Repeat Password: | |
|
| 3. Work Category * |
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| Select the category which best describes your work |
| Community Pharmacy |
| Hospital |
| Academia |
| Student |
| Industry |
| Government |
| Wholesaler |
| Physician |
| If Physician, please enter your specialty | |
| Other |
| If Other, please enter here | |
|
| 4. Type of Membership * |
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| The corresponding Annual Fee is indicated next to each type of membership |
| Individual - 24 € |
| Student - 5 € |
| Technician - 18 € |
| Non-profit organization - 50 € |
| Company - 100 € |
| Emerging Economy Member - 12 € (Click here for a list of countries) |
| Provider - 100 € |
|
| 5. Student Verification |
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| If You Are A Student or Post Grad indicate your advisor or department chair's name and email address for verification |
| Name: | |
| Expected Graduation Date (MM/YY): | |
| Email: | |
|
| 6. Current Memberships |
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| Please indicate the pharmaceutical compounding associations for which you are already a member: |
| Current Memberships: | |
|
Por motivos de seguridad introduzca el código que aparece en la imagen:
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