<p> American Pharmacists Association Academy of Student Pharmacists </p><p>Student Pharmacists Pin Order Form</p><p>Name: ______Contact Number: ______</p><p>School or College of Pharmacy ______</p><p>Address for pins to be mailed to (pins will be mailed FedEx Ground, No P.O. Boxes)</p><p>______</p><p>______</p><p>Number of Pins needed (Sold in bundles of 100 for $100.00)______</p><p>Payments accepted: Check (Payable to APhA-ASP), Money Orders, Credit Card</p><p> Check  Money Order  Invoice Chapter</p><p> Credit Card: Circle Card type below</p><p>Visa MasterCard American Express</p><p>Name as it appears on credit card: ______</p><p>Mailing address for card: ______</p><p>State: ______Zip Code: ______</p><p>Credit Card # ______</p><p>Exp. Date ______CVV Code: ______</p><p>Amount to be charged ______</p><p>Submit form with Payment to: </p><p> Mail or  Email [email protected] APhA-ASP Pin Orders Attn: Lynette Hamilton 2215 Constitution Avenue, NW Washington, DC 20037</p>