Mr Ms Mrs Miss

Name

Title

Company

Street Address

City

State/Province

ZIP Code/Postal Code

Telephone
-
Fax
-
Email Address

Highest Degree Earned

Send Mailings to: (Please check one!) Home Address E-Mail Employment/School Address

POSITION PLEASE CHECK ONE ONLY

Director of Pharmacy
Associate or Assistant Director
Supervisor, Senior Pharmacist
Clinical Coordinator
Staff Pharmacist
HMO
Gov't or Organization
Resident
Consultant Pharmacist
Community Pharmacist
College or Univ. Faculty
Pharmacy Technician
Pharmacy Student Full Time
Home Health Care
Other


Regional Chapters are listed by county merely for convenience and geographic reference.
Individual preference, residence, or employment can influence choice of Regional Chapter.
Please check preferred regional chapter

Northern: Bergen, Hudson, Passaic, and Sussex Counties
North Central: Essex, Morris, Union, and Warren Counties
Central: Hunterdon, Mercer, Middlesex, Monmouth, Ocean, and Somerset Counties
Southern: Atlantic, Burlington, Camden, Cape May, Cumberland, Gloucester, and Salem Counties
Ernest Mario School of Pharmacy Student


Type of Membership (12-month membership, starting with the month after the application has been processed.)
Practicing $ 120
Practicing (2 Year Option) $ 220
Joint Practicing (Husband/Wife) $ 180
Joint Practicing (2 Year Option) $ 325
Retired $ 40
Retired (2 Year Option) $ 65
Resident/Fellow $ 50

Associate
Supporting $ 120
Supporting (2 Year Option) $ 220
Pharmacy Technician $ 45
Joint Supporting $ 180
Joint Supporting (2 Year Option) $ 325
Pharmacy Student Full Time $ 20

I am interested in becoming more involved in activities of the Society. Please contact me to discuss the following:

I Involvement State Level (Place a check next to the heading and all categories that you are interested in)

A) State Officer Positions:
President-Elect
Secretary
Treasurer

B) Director Of:
Professional Affairs
Educational Affairs
Organizational Affairs
Technician Affairs
Legal & Public Affairs

C) Council Committee Membership
Professional Affairs
Educational Affairs
Organizational Affairs
Technician Affairs
Legal & Public Affairs
Other (specify)


II Involvement Chapter Level
(Place a check next to the heading and all categories that you are interested in)

A) Chapter Officer Positions
President-Elect
Secretary
Treasurer

B) Help plan monthly programs

Type of Membership
Active Membership
Pharmacists who are involved with and contribute to Pharmacy through their practice.
Retired pharmacist members of the Society.

Associate Membership
Non-pharmacists who by their supportive work contribute to Pharmacy through their practice.
Full time pharmacy students in accredited schools of pharmacy.

New Jersey Society of Health-System Pharmacists NJSHP

Payment Type: (Please Check One)

VISA MC AMEX
Name (as it appears on the card):
Billing Address of Card:
City:
Zip Code:
Credit Card Number:
Exp. Date (MM/YY):	01 02 03 04 05 06 07 08 09 10 11 12 2007 2008 2009 2010 2011 2012 2013 2014 2015
CVV code (on back):

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