PTEC Annual Membership Application Form

        PLEASE PRINT AND COMPLETE THIS APPLICATION FORM THEN MAIL IT, ALONG WITH YOUR CHECK TO THE ADDRESS BELOW.

        July 1, 20_____ - June 30, 20_____

        Active _____                                      I am involved in the education of pharmacy

        $80.00 US with Journal subscription        technicians

        $55.00 US without Journal subscription

        Associate _____                                 I am not involved in the education of pharmacy technicians

        $80.00 US with Journal subscription        but would like to support the activities of PTEC

        $55.00 US without Journal subscription      

        Corporate _____                                 I am not involved in the education of pharmacy technicians,

        $500.00 US                                        but would like to support the activities of PTEC. Place name

                                                                               of corporate representative here _____________________

          (Please Type or Print Legibly)

        ______________________________________________________________________

          NAME (First, Middle, Last):

          _______________________________________________________________________________________

          PROFESSIONAL TITLE (CPhT, R.Ph., RN, etc.):

          _______________________________________________________________________________________

          PROFESSIONAL TITLE (Director, Instructor, etc.):

          _______________________________________________________________________________________

          INSTITUTION NAME:

          _______________________________________________________________________________________

          PREFERRED MAILING ADDRESS: Street:    HOME:_________ WORK: _________

          _______________________   _______________________   ___________________   ________________

                         (city)                               (state)                                (zip)                        (country)

          (       )_______________________  EXTENSION: ________________

          PREFERRED TELEPHONE:  HOME: ________  WORK: ________

          PREFERRED E-MAIL ADDRESS: ________________________________________

          Preferred form for Newsletter: e-mail link_______ e-mail full document _______ regular mail hard copy _______

          If you have a special interest, or are willing to volunteer your time to work on a committee, please briefly explain your
          interests on the back of this application form.

Please make checks payable to: Pharmacy Technicians Educators Council (PTEC)

Send application and payment to:
PTEC Membership
c/o Ann Oberg
PO Box 89105
Sioux Falls, SD 57109-9105

If you would like to speak with someone in person about membership in the Pharmacy Technician Educators Council,
please call Mary Mohr President at 317-962-0919 or e-mail at mmohr@clarian.org