New Membership Form
Required Fields *
*New Member or Renewal?
Yes No
*First Name
*Last Name
*Sex
MF
*Email Address
*Home Address
Apt. #
*Home City
*Home Island
*Home State
*Home Zip
*Home Phone
Other Phone
Alternate Email
*Primary Employer
...If Other
*Primary Practice Type
...If Other
Secondary Practice Type
...If Other
Business Address
Business City
Business Island
Business State
Business Zip
Business Phone
Business Fax
License #
Degree(s)
(check all that apply)
PharmD
BSPhcy
CPhT
Tech
Other BS Degree(s) held
BA
 MBA
MSci
MPh
RN
PhD
other degree(s) held
Other Professional Memberships:
(check all that apply)
APhA
ASHP
NCPA
ASCP
NACDS
 HIP
ACCP
HAH
AMCP
Please select your areas of interest
Scholarship & Awards Committee
CE/Programs Committee
Membership Committee
Annual Meeting Committee 		Government Affairs Committee
Newsletter/Publications Committee
Finance Committee
Elections Committee
Other Membership(s) Held
Are you a CDE (Certified Diabetes Educator) ? Yes No
Are you BCPS certified? Yes No
Are you a CDM (Certified Disease Manager)? Yes No
Send me Email Yes No
Send me Postal Mail Yes No
*I authorize HPhA to release my name and contact information to other organizations only if information pertains to: future CE opportunities? Yes No
*I authorize HPhA to release my name and contact information to other organizations re: any pharmacy related information? Yes No
When you click "Continue" you should be redirected to the Hawaii Pharmacists Association Membership Payment area.