Membership Application
*First Name:	*Last Name:
Social Security Number:
Institution/Employer:
Street Address:
City:	State:
Zip:	Country:
*Home Address:
*City:	*State:
*Zip:	Country:
*E-mail:	Check here to be added to our e-mailing list for important membership updates
Work Phone:	Home Phone
Occupation/Title: R.N. Pharmacist Industry L.P.N. Pharmacy Tech Other
License Number: Student Membership (non-licensed student)
Credit Card Information:
Visa Mastercard American Express** Discover**
**5% servcice charge will be added when using Amercian Express or Discover
*Name on Card:
*Credit Card Number:
*Exp. Date: Month 01 02 03 04 05 06 07 08 09 10 11 12 / Year 08 09 10 11 12 13 14
New Renewal - Membership Number
Please make sure that all of the information is filled in before clicking the submit button. After you receive the submission thank you form please click the back button to choose another link on our site.

Signature (if mailed)__________________________________________

 

* required field

Annual Dues: $55.00 - Student Membership $20.00

If paying by check, please print out this form, make checks payable to "LITE" and mail to:

Empire Building, Suite 3, 3001 Jacks Run Road, White Oak, PA 15131

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To contact us:

Phone: 412-678-5025
Fax: 412-678-5040
Email: info@lite.org