PHILIPPINE PHARMACISTS ASSOCIATION, INC.

2014 NATIONAL CONVENTION

April 24-26, 2014 SMX Conv n!ion C n! r, "#v#o Ci!$

RE%ISTRATION &ORM
PERSONAL IN&ORMATION
TYPE OF REGISTRATION: LAST NAME GEN!ER: Ma"e &IRT'!AY: A!!RESS: #ONTA#T NO(: Pharmacist GI EN NAME Fema"e #I IL STAT$S: Student Non-Pharmacist MI!!LE NAME Sin%"e Married

EMAIL:

MEM'ERSHIP "ETAILS
ARE YO$ A PPhA MEM&ER): Yes IF YES* PPhA I!+: No #'APTER ,#ITY- PRO IN#IAL.: AFFILIATIO PA#OP IPAP !O'LP N: PAPPI YPG #OS'1ELL ,P"ease /our PS'P F2# PPhA a00i"iation. PAP I #PAP PR# NO(: ISS$E! ON: ALI! $NTIL: AREA OF #ommunit/ Pharmac/ PRA#TI#E: 'os3ita" Pharmac/ Go4ernment ,P"ease /our Manu0acturin% Others ,P"ease S3eci0/. area o0 3ractice. Academe S#'OOL GRA!$ATE!: YEAR GRA!$ATE!:

#O$RSE TA5EN:
,P"ease /our course ta6en.

+#n. ,1, 2014-

7 /r &S Pharmac/ 8 /r &S Pharmac/ 8 /r &S Industria" Pharmac/ Others ,P"ease S3eci0/. RE%ISTRATION AN" MEM'ERSHIP &EES E#rl$ 'ir( Pr -r .i/! r ( R .*l#r #n( On)*p !o /i! )*p !o M#r01 ,1, 2014)April 1, 2014 #n( on2#r(/
P1p 8*88:(:: P1p 7*8::(:: P1p ;*:::(:: P1p M 45 r/1ip 3 P1p P1p P1p 8::(:: A4o*n! ;*:::(:: 8*:::(:: ;*8::(::

Pharmacist P1p 7*9::(:: Student P1p 7*8::(:: Non Pharmacist P1p 8*8::(:: Mem<ershi3 0ee 0or =:>7 To!#l & / R .i/!r#!ion 3

MO"E O& PA6MENT O& &EES

>( A"" chec6s and cash 3a/ments ma/ <e 3aid to the P1ilippin P1#r4#0i/!/ A//o0i#!ion,In0 (* "ocated at 9>8 R( Pa3a St( Sam3a"oc Mani"a thru M/. "i#nn M#ri7 R. So/#* PPhA E?ecuti4e Assistant( O00icia" recei3t @i"" <e issued u3on 3a/ment( Or /ou can de3osit at the <an6 <e"o@(
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'AN8 TO 'AN8 "EPOSIT

!e3osit to PPhA Account No 0,41-020961-002 SE#$RITY &AN5 IN#( Mendio"a &ranch or to PPhA Account no 0020,91,:0 &AN#O !E ORO* Recto &ranch( 1rite /our name and date o0 de3osit in the de3osit s"i3( You can scan /our de3osit s"i3 and send </ emai" to 3hi"3harm(natconA%mai"(com (
U U U U H

#on0irmation o0 /our <an6 de3osit @i"" <e done </ emai"( O00icia" recei3t o0 3a/ment to PPhA @i"" <e issued on-site in the 3re-re%istration area(

CANCELLATION O& RE%ISTRATION &EE

I0 @ritten reBuest 0or cance""ation is recei4ed on or <e0ore A3ri" >>* =:>7* 8:C o0 re%istration 0ee @i"" <e reim<ursed( ReBuest 0or re0und o0 re%istration 0ee a0ter A3ri" >>* =:>7 @i"" not <e entertained(