Vendor Contracts/Application     Services/Affiliates     IPA News 

   APPLICATION FOR MEMBERSHIP TO IPA

      Rev.2/07

Please accept my pharmacy into IPA membership with a Lifetime Membership Fee of only $7.95.

PHARMACY NAME _______ _____________ CORP NAME _

ADDRESS        ___  E-MAIL ______________________________

CITY ______________   ST _____   ZIP CODE __________   COUNTY _____

TELEPHONE _____________________  FAX _______________________  CELL (optional)  

DEA #________ NCPDP #_____ _____________ NPI #  _______

                                (for manufacturer’s rebates)                   

OWNER’S NAME ____________________ FRONT MANAGER __________________

OTHER BUYING GROUP AFFILIATIONS 1.________________________                   2.________________________

A complete contract book will be sent upon receipt of this application.

1.                                                         $                                              / month                                                    ___

2.                                                         $                                              / month                                                    ___

A)     ACTUAL SQUARE FOOTAGE   OR APPROXIMATE STORE SIZE (sq. ft.):

q 1000-2500;           q 2500-5000;           q 5000-7000;           q 7000 & up

B)    ANDA / VIP PROGRAM:  q  VIP Acct #:  _______________    q ANDA Acct. #:  _______________

C)    VITAMINS/NATURAL SUPPLEMENTS: q Nature’s Bounty  q Windmill Vitamins q Other________

Are your vitamins purchased Direct  q Yes   q No-through my wholesaler (Name)________________

D)    INSURANCE (BOP, Professional, General Liability, Auto, etc.):

Would you entertain a quote on your Business Owners Insurance Policy?  q Yes    q No

E)     GREETING CARDS:  q Carlton Cards  q Gibson  q Am. Greetings  q Freedom Greetings  Other_______

Are your cards Billed Direct:  q Yes     q No - through my wholesaler (Name)________________________

F)     PHOTO FINISHING:  Do you use:  q Qualex/Kodak  q Photo Experts  q Other___________________

G)    VISA/MASTERCARD: Do you use:  q Heartland Payment Sys q Global  q Healthcard  q Other_______

H)    PAYROLL:  Do you use:  q Heartland Payment Systems  q ADP   q Paychex   q Other____________

Thank you for adding your strength to the over 2,100 NY, NJ, PA and CT independent pharmacies that are members of IPA.  Your signature allows you to participate in any IPA program of your choice and gives IPA your consent to receive faxes sent by or on behalf of IPA.  FYI: 95% of all faxes are limited to 1 page for third party, legislative and co-op information.

                                                                                                     ____________________

   Authorized Signature                                                                  Date