Corporate Membership Application

The following information is required to have the PDE Board of
Directors consider your application for membership in the PDE.
Company Name:
Address Line 1:
Address Line 2:
City:
State:
Zip Code:
Website:

Nature of Business:
   Pharmaceutical Manufacturer  Chemical Supplier 
 Allied Trade (Specify)
Type of Organization:
   Corporation  Private  Publicly Held  Division 
  Name of Parent Company: 
  Individual 
Annual sales:
Annual sales to the drug industry:
Number of drug industry customers:
Number of employees:
Date Founded:

Company Information

Describe key product line(s) or service(s) provided:

Interest in the PDE

Please state why your company is interested in joining the PDE:

Company Representatives

Please give the following information for the persons who would represent your company with the PDE as:

Official Correspondent: (Primary contact)

Name:
Title:
Preferred Mail Address:
City:
State:
Zip Code:
Office Phone:
Cell Phone:
E-Mail Address:
 
 

$495 payable to “PDE” and will be billed after membership approval.