Name:

Address:

City State and Zip:

Home Phone:

Work Phone:

E-mail address:

Should we list your e-mail address on our home page? Yes No

If you don't want a Web page listing, should we send you IPA updates to your e-mail address? Yes No

If you don't want a Web page listing, can we list your first name and e-mail address in the CLOSED pages on our snailmail list, which is sent to members only? Yes No

Sex: Male Female

Birthdate:

Practice or Speciality: Community, hospital, industry, addiction, etc.

Degree(s): BS MS/MA PharmD PhD MD Student
Multiple items may be chosen.

Professional License: Current Revoked Reinstated Student

Any license restrictions?:

12 Step Affiliation(s): AA NA GA Al-Anon Nar-Anon Other
Multiple items may be chosen.

Where did you hear about IPA?:

Are you willing to help another pharmacist in your area? Yes No

Restrictions in contacting you or giving your first name and number to new or travelling members?:

Significant Other (optional):

Sober/Clean Date: