Wufoo

Membership Application

Please fill out the membership application. We'll be back to you as soon as we've received your information.

Tell us a little bit about your organization
What is the formal name of your organization? *
Maximum Allowed: 120 characters. Currently Used: 0 characters.
Your Organization's Website *
What kind of organization are you? *
Academic Multilateral Pharmacy Regulator Industry Patient Policy Other
If Other, please describe
Maximum Allowed: 120 characters. Currently Used: 0 characters.
Please indicate the activities which interest you most:
Publications and Policy Public Awareness (includes media) Professional Development (designing continuing ed curricula) Other
Please describe your organization’s program, policy, or procedure to protect consumers from contraband or counterfeit drugs: *
If Other, please describe
Maximum Allowed: 120 characters. Currently Used: 0 characters.
Tell us a little bit about how to get in touch with you
Your Name * First Last
Your Title *
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Web Site
Email *
Phone (US) ### - ### - ####
Phone (International)
Maximum Allowed: 80 characters. Currently Used: 0 characters.
Who Else At Your Organization Should Receive Regular Updates From Us?

We send out regular alerts with news and information about counterfeit drugs. Please list the e-mail addresses of any other staff members at your organization that should be added to these announcements.
Email
Email
Email
Affirmation

My organization supports the Partnership for Safe Medicines’ purpose to promote the safety of prescription drugs and the protection of consumers against counterfeit or contraband medicines. In support of that purpose, I affirm that my organization does not support or facilitate the illegal purchase, distribution or use of counterfeit or contraband medicines.
You must check this box to affirm your application *
I agree to the paragraph above and am legally entitled to sign on behalf of my organization.
Further Questions

If you have further questions about this form please contact us at +1-866-300-1077 or information@safemedicines.org.
Do Not Fill This Out

Wufoo

Membership Application

Tell us a little bit about your organization

Tell us a little bit about how to get in touch with you

Who Else At Your Organization Should Receive Regular Updates From Us?

Affirmation

Further Questions