Student Pharmacist Membership Application This CPhA Membership Application is for student pharmacists only. Student Pharmacist Membership Interest FormWhich Pharmacy School are you currently attending?*Please select oneCalifornia Health Sciences UniversityCalifornia Northstate UniversityChapman University School of PharmacyKeck Graduate InstituteLoma Linda UniversityMarshall B. Ketchum UniversityTouro University CaliforniaUniversity of California San DiegoUniversity of California San FranciscoUniversity of the Pacific, Thomas J. Long School of Pharmacy and Health SciencesUniversity of Southern CaliforniaWest Coast UniversityWestern UniversityMembership Type* New Member Returning Member Personal InformationName* First Middle Last Gender* Male Female Date of Birth* Month Day Year Degree(s) Earned* BA BS MS MBA MPH PhD Other: Type of degree:* Anticipated Graduation Year* School Email Address* License/Intern Number* Cell PhonePhone Number*Personal Address(while attending school)Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Permanent AddressAddress* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Please select the following membership classification for this application.* Student Pharmacist (Assigned to Academy of Student Pharmacists - Membership dues are to be paid to the student pharmacist chapter) Local Association Membership is based on personal address zip code.If you would like to change your assigned local association zip code, please provide below: Special Interest Group (SIG) Membership(Select one Special Interest Group, in addition to the Academy of Student Pharmacists) Compounding SIG Community Pharmacy SIG Ambulatory Care SIG Long Term Care SIG Managed Care SIG Inpatient Care SIG Pharmacy Ownership SIG Pharmacy Technician SIG Δ
