Maine Society of
 Health-System Pharmacists

Membership Application / Renewal Form

Name: _____________________________________________________________

Address: ___________________________________________________________

City:_________________________________  State: ____  Zip: _______________

Telephone Number:___________________________________________________

E-Mail Address: _____________________________________________________

Employer: __________________________________________________________

Please check one:    [   ] New Membership Application       [   ] Membership Renewal Application

[   ] Regular Membership (3 Year): $120 for three years

[   ] Regular Membership (1 Year): $50 for one year

[   ] Technician Membership (1 Year): $15 for one year

[   ] Technician Membership (3 Year): $35 for three years

[   ] Resident Membership: $15 for one year

[   ] Student Membership: $0 - Expected Year of Graduation:___________________

[   ] Retired Pharmacist Membership (1 Year): $20* for one year

[   ] Retired Pharmacist Membership (3 Year): $50* for three years
                                                                    *Free if you agree to serve on a committee!

Please mail application and check (payable to Maine Society of Health-System Pharmacists) to:

Steve Townsend, PharmD
Pharmacy Supervisor
Harold Alfond Center for Cancer Care
361 Old Belgrade Rd
Augusta, ME  04330