Retired 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 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:
    $75 Retired
    payable to “PDE” and will be billed after membership approval.