Membership Renewal Form for AFPS Individual Member

This is to

Withdraw

Change

1. Member ID (e.g. 712-XXX-XXXX)

2. Country Category

3. Are you a Student?

[Non-Student]

[Student]

4. Check the appropriate box

[Ms.]

[Mr.]

[Dr.]

5. Family Name

6. Given Name

7. Gender

[Male]

[Female]

8. Date of Birth (YYYY/MM/DD)

9. The address listed is

[Business]

[Home]

10. Company / Institution (e.g. Dept. of Pharm. Sci., Univ. of *****)

11. Address, City, State, ZIP (e.g. 123 Medicine St., Bunkyo, Tokyo 113-0000)

12. Country

13. E-mail

14. Retype E-mail (Please enter the same E-mail address as above)

15. Phone (Country Code)

+ -

16. Phone (Local Number)

17. Fax

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