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Pharmacy Quality Alliance

6213 Old Keene Mill Court
Springfield, VA   22152

Phone: (703) 690-1987
Fax: (703) 842-8150

To contact us, email:
info@pqaalliance.org
or click here.

Membership Application


To join PQA, please complete the information shown below.  If you would prefer to submit your application by mail or fax, please download our Membership Application, here.

For membership questions, please contact Jackie Green, Chief Operating Officer at (703) 927-1599 or jgreen@PQAalliance.org.

Your Organization
Name of Organization
Address
Address Cont'd
City
State
Zipcode
Phone (Main)
Phone (Fax)
Full Website URL
Type of Organization
  Other:

Application Prepared By
First Name
Last Name
Credentials
Phone
Phone (Cell/Other)
Email Address
Position/Title

Primary Contact (for voting, communications, measure development team appointments)
Use the same contact information as 'Application Prepared By'. If checked, skip this section.
First Name
Last Name
Credentials
Phone (Direct)
Phone (Cell/Other)
Email Address
Position/Title

Invoicing Contact
Use the same contact information as 'Application Prepared By'. If checked, skip this section.
First Name
Last Name
Credentials
Phone (Direct)
Phone (Cell/Other)
Email Address
Position/Title

Membership Structure (only one category may be selected in the Membership Structure)
Non-Profit Organizations - Annual dues are based on annual operating budget
Select one: Less than $500,000 $1,375
  $500,000 to $4,999,999 $5,500
  $5 million to $10 million $8,250
  $10 million to $50 million $16,500
  Over $50 million $27,500
For-Profit Corporations - Dues based on annual U.S. sales
  Less than $4 million $3,300
  Between $4 million and $10 million $6,050
  $10 million up to $50 million $9,075
  $50 million to $250 million $18,150
  $250 million to $1 billion $30,250
  Over $1 billion $34,375
Community Pharmacy Retailers - Dues are based on store count
  5 or fewer stores $1,375
  6 to 10 stores $3,000
  11 to 30 stores $5,500
  31 to 125 stores $8,250
  126 to 500 stores $16,500
  Over 500 stores $27,500
Academic Institution - All Academic Institution memberships include one complimentary attendee registration at the Leadership Summit and Annual Meeting.
  Academic Institution Membership $500
State or Federal Agency
  Government Membership No charge

Remittance Information*

Make checks payable to PQA, Inc. and mail to:
Charlene Lane, Administrator
PQA, Inc., 6213 Old Keene Mill Court, Springfield, VA 22152

To request an electronic invoice please email your organization's name, complete mailing address
and the invoicing contact person to Charlene Lane at clane@PQAalliance.org.

* A printer-friendly invoice can be printed after this page is submitted.
A copy will also be sent to the email address entered in the 'Application Prepared By' field.

Membership Application Submission
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