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: 

     
     

    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.