American Pharmacists Association

American Pharmacists Association Academy of Student Pharmacists

Student Pharmacists Pin Order Form

Name: ______Contact Number: ______

School or College of Pharmacy ______

Address for pins to be mailed to (pins will be mailed FedEx Ground, No P.O. Boxes)

______

Number of Pins needed (Sold in bundles of 100 for $100.00)______

Payments accepted: Check (Payable to APhA-ASP), Money Orders, Credit Card

 Check  Money Order  Invoice Chapter

 Credit Card: Circle Card type below

Visa MasterCard American Express

Name as it appears on credit card: ______

Mailing address for card: ______

State: ______Zip Code: ______

Credit Card # ______

Exp. Date ______CVV Code: ______

Amount to be charged ______

Submit form with Payment to:

 Mail or  Email [email protected] APhA-ASP Pin Orders Attn: Lynette Hamilton 2215 Constitution Avenue, NW Washington, DC 20037