APhA-ASP/IPSF Chapter Liaison Contact Form

Please complete the following contact information form. Your contact information will be used by the APhA-ASP/IPSF National Officers to send periodic updates about IPSF activities, projects and upcoming meetings/programs. Your name and e-mail address will also be added to the YahooGroups APhA-ASP/IPSF Listserve. If you have any questions, please contact APhA-ASP/IPSF National Contact Person via e-mail at usaipsfcp@yahoo.com.

Please choose your Region:

(Click here for a list of the APhA-ASP Regions.)

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Please choose your School or College of Pharmacy:

If your school or college of pharmacy has multiple campuses or satellite campuses, please choose the campus that you represent.

Multi-Campus or Satellite Campuses:

APhA-ASP/IPSF Liaison Contact Information

First Name:

Middle Initial:

Last Name:

Email Address During School Year:

Mailing Address During School Year:

City:

State:

Zip Code:

Phone Number:

APhA Member ID#:

Term as Chapter IPSF Liaison Ends: