Individual Membership Application

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

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.