Alberta Independent Pharmacy Association (AIPA)

Membership Registration & Agreement Form

Full Name(Required)

First Last

Gender(Required)

Male

Female

Other / Prefer not to share

Date of Birth(Required)

Pharmacy Name:(Required)

Pharmacy Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Pharmacist License Number:(Required)

Pharmacy License Numbers (For pharmacy owners):

Email Address:(Required)

Phone Number (Mobile):(Required)

Phone Number (Pharmacy):

Membership Category & Benefits

Please select one:(Required)

Regular Member - Pharmacy Owner or Co-Owner ($250/year-Starting 1st July to 30th June). Voting rights, advocacy representation, access to strategic meetings, resources, and policy influence.

Associate Member - Independent, Casual/relief, or Freelance Pharmacist ($150/year-Starting 1st July to 30th June). Voting rights, participation in committees, networking, professional development, and engagement in policy dialogue.

Agreement & Declaration

By signing below, I hereby:

1. Agree to support AIPA's mission, vision, and values.

2. Acknowledge the accuracy of the information provided.

3. Understand that membership dues are non-refundable.

4. Authorize AIPA to contact me with updates and advocacy notices.

5. Consent to my name and pharmacy being listed in AIPA's member directory (unless opted out).

6. Commit to abiding by AIPA's bylaws, code of conduct, and policies.

Privacy & Consent

AIPA complies with Alberta's Personal Information Protection Act (PIPA). Your information will only be used for membership management and advocacy-related communications.(Required)

I consent to the collection and use of my information for AIPA purposes.

Signature

Signature of Applicant:(Required)

Date:

Regular Member - Pharmacy Owner or Co-Owner ($250/year)

Price:

Associate Member - Independent, Relief, or Freelance Pharmacist ($150/year)

Price:

Total

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Alberta Independent Pharmacy Association (AIPA)

Membership Registration & Agreement Form

Membership Registration & Agreement Form

Membership Category & Benefits

Agreement & Declaration

Privacy & Consent

Signature

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