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: 


Company Information

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

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.