Printable Membership Application and Renewal
If you wish, you may enroll online at the "PFLI Store"; please mail in with your payment to the address below OR you may fax this to us if paying by Visa, MasterCard or Discover. Fax number is 740-206-1260.

Name
Address
City
State / Province Zip Code
Work Address
City 
State / Province Zip Code
Preferred Address Home Work
E-Mail Address
Telephone Number

 

    Membership
      New Renewal
       
       
       

    Do you wish to receive PFLI updates by email?

      Yes No
       
       
       

    Annual Dues

      Pharmacist Membership $50.00 (U.S.)
      Non-Pharmacist/Retired RPh Membership $25.00 (U.S)
      Student/Pharmacy Tech Membership $15.00 (U.S)

    Payment Method

      Credit Card      Please call 1-800-227-8359 or 740-881-5520 with card number after submitting this form. Or fax it with your credit card number (Visa, MasterCard or Discover) & expiry to 1-740-206-1260. Or you may enroll/renew your membership at the "PFLI Store" on the Home Page link!
      Personal Check
      Money Order

      Please make check or money order payable and mail to: Pharmacists for Life International - Member Services PO Box 1281 | Powell, OH | 43065-1281 | USA after submitting this form. Be sure to include address, telephone number and email address with check or money order. Please make sure to mail a printed copy of this in with your payment or it will not be processed. Thanks!

       We welcome your comments, concerns, suggestions and constructive criticisms. We hope you'll share your opinions and talents with us!


     
To help PFLI serve you better, please respond to the following sections as completely as possible.

 
 
    Hours worked per week
      20 or less 20 to 25 26 to 32 33 to 39 40 or more
       
       
       
    Work parameters   Check all that apply.
      Multiple locations (floater) Independent Chain Hospital Clinic HMO Managed Care Industry Government Other
       
       
       
    Rx / consults / cognitive services per day
      Less than 100 101 to 200 201 to 300 301 to 400 More than 400
       
       
       
    Gender
      Male Female
       
       
       
    Religious affiliation
     
     

    Please rate reason(s) for joining PFLI.
    (5) indicates maximum influence   (1) indicates minimal influence
     
     

      Conscience Clause
      5 4 3 2 1

       Religious / Moral Reasons
      5 4 3 2 1

       Professional integrity threatened
      5 4 3 2 1

       Enhance knowledge about life issues affecting RPh's
      5 4 3 2 1

      Other
      5 4 3 2 1
      Please specify 
       
       
       

    Others issues / problems that are affecting you know or threatening to do so in the future.
     
     
      Insurance and government mandates against your conscience

      High volume / Fixation on the "numbers"

      Inability to practice as educated

      Consolidation of profession vertically by manufacturers / insurance providers / PBMs

      Imposition of secular anti-life values on you in the workplace

      Other

       Please specify 

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The contents of your application will remain visible after your application has been submitted. REMEMBER, nothing will happen with this application until you fax or send it in WITH your membership dues payment. For an instant application, enroll or renew your membership at the
PFLI Store
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Thank you! Welcome to Pharmacists for Life International, the only pharmacy association which is exclusively 100% total protection pro-life!

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