KCHP Membership Application
Please fill out the form below as completely as possible.

Name:
 Employer Name:
   
Position/Job Title:
 Employer Address:
   
Recruiter Name (if applicable):
 Employer City/State/Zip:
   
Home Address:
 Work Phone:
   
City/State/Zip:
 Work Fax:
   
Home Phone or Cell:
 Preferred Email:
   
Graduation Date:
 Degree(s):
   
College of Pharmacy:
  
   

Preferred Mailing Address:

  Home         Work
Preferred Phone:   Home         Work
   

MEMBERSHIP CATEGORIES
Please check the category for which you are applying:
  Pharmacist $ 125
  Associate/Supporting Member $ 125
  Joint (Pharmacist) Membership $ 200
  Retired Pharmacist (65 yrs or older) $   35
  Technician/Retired Technician $   35
  Student $   20
  New Grad: 1st year/PGY1 $   45
  New Grad: 2nd year/PGY2 $   90
   

     

Join the Wichita Academy of Pharmacists for just $75 more!

To proceed with this registration form, please
enter the security code of the major credit card
(Visa, MasterCard or American Express) you will
be using to complete online registration.