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Annual Convention
Convention Registration Form
Contact Information
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Full Name
*
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Email
*
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State
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ZIP
Spouse/Guest Name (if attending)
eProfile Number
*
Business/School Information
Name
*
Phone
*
Address
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State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
DC
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP
Convention Registration Type
Full Registration
QTY
Early Bird Pricing
(Through August, 23rd 2024)
Regular Pricing
(After Aug. 23rd 2024)
TOTAL
SDPhA Member
Early Bird Pricing
$249
Regular Pricing
$325
SDAPT Member
Early Bird Pricing
$115
Regular Pricing
$150
Pharmacy Tech (non-SDAPT)
Early Bird Pricing
$199
Regular Pricing
$205
Pharmacy Student
Early Bird Pricing
FREE
Regular Pricing
FREE
Non-SDPhA Member
Early Bird Pricing
$350
Regular Pricing
$375
One-Day Registration
Friday, September 13th
QTY
Pricing
TOTAL
SDPhA Member
Pricing
$200
SDAPT Member
Pricing
$105
Pharmacy Tech (non-SDAPT)
Pricing
$179
Pharmacy Student
Pricing
FREE
Non-SDPhA Member
Pricing
$250
Saturday, September 14th
QTY
Pricing
TOTAL
SDPhA Member
Pricing
$100
SDAPT Member
Pricing
$105
Pharmacy Tech (non-SDAPT)
Pricing
$130
Pharmacy Student
Pricing
FREE
Non-SDPhA Member
Pricing
$125
I would like to sponsor a student
Sponsorship Amount
I would like to contribute to the SDPhA Commerical & Legislative Fund
Credit Card Administration Fee
Registration Total Due
Credit Card Information
Membership fees total to $100. By placing your card information and submitting this form, you give SDPhA permission to charge $100 to your card.
An administrative fee of 3% will be applied to all transactions.
Cardholder Name
*
Card Number
*
Expiration Month
*
--Month--
01
02
03
04
05
06
07
08
09
10
11
12
Expiration Year
*
--Year--
2024
2025
2026
2027
2028
2029
2030
2031
CVV#
*
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