Maryland Society of Health-System Pharmacists

8480-M Baltimore National Pike, #252
Ellicott City, MD 21043
Phone: (410) 465-9975 , Fax: (410) 465-7073
E-mail: mshp@rxassociationmgt.com, Web Site: www.MSHP.org

Application  (Print and Mail Version)

Play an active role in shaping your profession. Join MSHP.

MSHP helps you stay in touch with our changing environments, learn new skills, identify opportunities, make contacts and advance your career. How? By participating in our monthly meetings where you can meet colleagues, share ideas, and gain up to 20 hours of ACPE approved education yearly. Additional opportunities are available through participation on one of our many committees.

I want to join MSHP. (Please print and circle appropriate membership type and remit proper amount.)

Active Member Dues $78.00

(Licensed pharmacists who have an interest in health-system pharmacy practice.)

New Graduate Member Dues $48.00

(Licensed pharmacists who have graduated from a five or six year school of pharmacy in last calendar year.)

Student Chapter

(Individuals currently enrolled in an entry level program at a School of Pharmacy and a member of the ASHP-Student Chapter are automatically registered as an MSHP member. Students can contact MSHP headquarters for the current student liaison representative at their School. Student chapter members are welcome to participate in all MSHP functions.)

Pharmacy Resident Member Dues $ 36.00

(Individual currently enrolled as a Pharmacy Resident or Pharmacy Fellow)

New Graduate $48.00

(Recent graduates of Pharmacy School)

Associate Member Dues $78.00

(Individuals who work as representatives in related companies, inspectors of health-system pharmacies or instructors of prospective health-system pharmacists.)

Pharmacy Technician Dues $36.00

(Technicians who have an interest in health-system pharmacy.)

Supportive Personnel Member Dues $ 36.00

(Includes other personnel working in health-system pharmacy.)

Senior Member Dues $60.00

(Current or previously licensed pharmacists of age 60 or greater.)

Payment Amount: $______ Check/Charge (MC or VISA)

Please Note: MSHP membership dues are for 12 months. Dues are not deductible as a charitable contribution under the Internal Revenue code, but may be deducted under other provisions of the Code.

MC/VISA/AMEX Number _________________________________________ Exp.: _________

Name as it Appears on credit card: ______________________________________________

Personal Data

Name: ________________________________________________________________________________

Preferred Address: ________________________________________________________________________________

City:_________________________________________ State:___________ Zip:_______________

Daytime Phone: (____)______________________
Alternate Phone: (____)_____________________

FAX: (____)______________________________ E-mail Address: ___________________________________

Institution: ___________________________________________________________________________________

Practice Setting: Hospital , Home Care/Home Infusion, Industry, Long Term Care, Academia

Community/Ambulatory Care, Managed Care Organization, Other ________________

Technicians- CPhT Yes / No

Pharmacy Position:

Director of Pharmacy	Associate Director of Pharmacy	Assistant Director of Pharmacy
Clinical Specialist	Staff/Clinical Pharmacist

Pharmacy Responsibilities: P&T Member, Advisor Influence, Enforce P&T decisions

ASHP Member: Yes / No

Committees of Interest:

Educational Programming	Biannual-All Day Seminars	Evening Monthly Programs
Communications	Legislative	Publications
Industry Advisory	Emergency Preparedness	Membership/Techinicans
Finance	Medication Safety	Learning Education Research
Student Mentoring	Public Affairs

Please indicate legislative district here (if known) ___________

Signed: __________________________________ Recruited by: ________________________________ Date: __________