AP-PAC Membership Application
Please print this form and mail to
AP-PAC
417 S. Victory
Little Rock, AR  72201

2007-2008 Membership

Designation: (circle one)
P.D.     Pharm.D.     R.Ph.     Other
Pharmacist License Number____________
Last Name: _________________________
First Name: _________________________
Address: ___________________________
City: _______________________________
State: ______________ Zip: ____________
Employer: __________________________
Work Phone: ________________________
Work Fax: __________________________
Home Phone: _______________________
Email address: ______________________

Contribution Levels

Platinum member: $1000 or more
Gold member: $500 - $999
Silver member: $250 - $499
Bronze member: $50 - $249

I am enclosing a check in the amount of $__________ made payable to AP-PAC.

 I would like to be a legislative contact for Senator_________________________, Representative ____________________ or ___________________County.

AP-PAC fiscal year begins July 1st - June 30th. Contributions received at this time are
effective for 2004-2005 membership.
All or a portion of AP-PAC contributions are
eligible for a credit against your
Arkansas state tax.