Individual Membership Application

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

Nature of Affiliated Organization:
  Pharmaceutical Manufacturer  University/College 
 Allied Trade (Specify)
Type of Organization:
  Corporation  Private  Publicly Held  Sole Proprietor  University/College  Division 
  Name of Parent Company: 

 
 
Below not applicable to Student Applicants
Annual sales:
Annual sales to the drug industry:
Number of drug industry customers:
Number of employees:
Date Founded:

Company University Course of Study Information

As applicable, describe key product line(s) or service(s) provided or course of study for student
applicants:

Interest in the PDE

Please state why you are interested in joining the PDE:
 
 

Yearly membership dues are:
$125 Individual
payable to “PDE” and will be billed after membership approval.