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 

    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:

    Corporate Dues entitles every employee, of a member company, to participate in all of the PDE’s annual events at the member rate

    Please list employees who will participate in company membership

    Name:
    E-Mail Address:
    Name:
    E-Mail Address:
    Name:
    E-Mail Address:
    Name:
    E-Mail Address:
     
     

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