COMMERCIAL AND LEGISLATIVE CONTRIBUTIONS
AND DISTRICT DUES
October 1, 2012 through September 30, 2013
Fields marked with '*' are required..
First *  Middle   Last *
Mailing Address 1 *
Mailing Address 2 
City *
State *  Zip Code *(5 Digits)
Home Phone (No Dashes) * 
Mobile Phone (No Dashes) 
E-mail Address  *
Do you wish to receive SDPhA email alerts regarding important pharmacy issues?
2012 - 2013 Commercial & Legislative Fund
(Memberships set by SDPhA C & L Executive Committee, 2007)
PHARMACY OR BUSINESS MEMBERSHIP ($100.00) - (Includes One Individual Membership)
Name of Pharmacy/Business  
Name of Individual Included  

CORPORATE MEMBERSHIP ( $200.00)-(Two or more stores of the same corporation )
Name of Corporation  
Name of Individual Included  

INDIVIDUAL MEMBERSHIP
 $50 Level
 $75 Level
 Any Amount $
 Pharmacy or Business Fee Amount .......................................$
 Corporate Fee Amount ...............................................................$
 Individual Fee Amount ................................................................$

DISTRICT DUES
District Dues ( As shown, please select your district ) .........................................
Aberdeen-$10.00; Black Hills-$20.00; Huron-$10.00; Mitchell-$10.00;
Rosebud-$10.00; Sioux Falls-$20.00; Watertown-$10.00; Yankton-$10.00
Mobridge-$10.00
TOTAL TO BE CHARGED TO CREDIT CARD
CREDIT CARD DETAILS
(Note: The credit card number will be entered on a secure screen following this screen.)
Credit Card Type *
First Name *
Last Name *
Billing Address *
City, State/Province & Zip Code * , -
Do you wish to have this payment post to your credit card annually? No
Yes
  

You will have opportunity to review the above information before completing the transaction.