Membership/Renewal Application

Communications Consent I consent to receive communications sent by or on behalf of the Pharmacy Society of Wisconsin by any method used by PSW.
Employment Status
Clinical Coordinator Consultant Director/Manager Faculty Graduate Student Resident Owner	Pharmacy Technician Pharmaceutical Industry Retired Staff/Clinical Other:

Full Time (>30 hrs/wk) Part Time (10-30 hrs/wk) Occasional/Relief (<10 hrs/wk)
Primary Practice Areas:
Academia Ambulatory/Chain Ambulatory/Clinic Ambulatory/Independent Home Infusion Hospital-Inpatient	Hospital-Outpatient Long Term Care Managed Care/Administration Managed Care/Clinic Other:

Professional Memberships
APhA ASHP ASCP NCPA AACP	ACCP ASPEN AMCP Other:

Member Interests:
Educational Programming Legislative Affairs Medicaid Advisory Membership Recruitment Patient Safety Quality Improvement	Publications Student Mentoring Technician Programming WPRN Other:
What do you most value about your membership in PSW?
What benefits or services would you like to see included in your membership that aren't now available?
What current practice issues are most important to you?
Do you have suggestions for educational topics at future meetings? (Please be specific)

Dues Information

Full/Active (ACT) "Pharmacist"	$230
Pharmacy Student (S)	$10
Technician (T)	$60
Associate (ASO) "Non-Pharmacist"	$230
Retired (RET)	$115
Graduate Student/Resident (GRA)	$65
1st year Pharmacist (PL1)	$65
2nd year Pharmacist (PL2)	$115
Joint Spouse (JOI)	$360 ($180 each)

Yes, I would like to be a part of the Long Term Care Section.  Dues for the Long Term Care Section are an additional $45 ($22.50 for Retired members).

Voluntary Contributions to the Wisconsin Pharmacy Foundation: The Wisconsin Pharmacy Foundation, a privately held foundation of the Pharmacy Society of Wisconsin, is chartered to provide unique educational programs for Wisconsin pharmacists and to pursue pharmacy practice research projects. All contributions to the foundation are fully tax deductible, as a charitable gift, under the rules of the IRS. Your generosity is appreciated. Please accept the following contribution to the Wisconsin Pharmacy Foundation...$

Sponsor a Student You can sponsor a UW pharmacy student's attendance at 3 PSW meetings for just $75 through the Wisconsin Pharmacy Foundation. Your tax deductible contribution will support a student at PSW' s Legislative Day, Educational Conference and Annual Meeting. Please accept the following student sponsorship to the Wisconsin Pharmacy Foundation...$

Voluntary Contributions Friends of Pharmacy Fund: The “Friends of Pharmacy Fund” (FPF) is a political conduit that will help us better support pro-pharmacy political candidates.  To truly be successful and to have the impact that pharmacy needs, membership support of the FPF is absolutely critical. Contributions must be made through either a personal check or personal credit card. Corporate contributions are not possible. FPF Contributor Recognition Levels: Bronze: $25.00 - $99.00   Silver: $100.00 - $249.00   Gold: $250.00 - $499.00   Platinum: $500.00 and above Please consider a contribution with your application. Please accept the following contribution to the Friends of Pharmacy Fund...$

 

I will mail my payment.

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