Membership form

                 CAPA Membership Registration

LAST NAME:...........................................FIRST: .....................................................

Address: ...............................................................................................................................................................

City: .......................................................................................................State:........................................................

Home Phone............................................................. mobile # .........................................................................

EMAIL Address: (*very important) ....................................................................................................................

Place of Employment: ......................................................................................................................................

Job Title:...............................................................................................................................................................

Work Address:.....................................................................................................................................................

Phone ..............................................................................FAX ...........................................................................

MAKE CHECKS PAYABLE TO:        CAPA     dues: $ 35.00

check one:   _____ Pharmacist Member

                    _____ Technician Member