Individual Membership Application
The following information is required to have the PDE Board of
Directors consider your application for membership in the PDE.
Directors consider your application for membership in the PDE.
Name:
Address Line 1:
Address Line 2:
City:
State:
Zip Code:
Email:
Company or University Affliation:
Nature of Affiliated Organization:
Pharmaceutical Manufacturer University/College
Allied Trade (Specify)
Allied Trade (Specify)
Type of Organization:
Corporation Private Publicly Held Sole Proprietor University/College Division
Name of Parent Company:
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:
applicants:
Interest in the PDE
Please state why you are interested in joining the PDE: