Name* First Last Email* Phone*Number of Pharmacy Locations*If you have multiple Pharmacy locations, please upload a list of them here including their full addresses:Pharmacy Name*Website Address* Job Title*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Wholesaler*Secondary Wholesaler*What is your monthly brand rebate percentage?What is your monthly generic rebate percentage?When does your contract expire? Date Format: MM slash DD slash YYYY Do you receive any tech rebate, other fees, or discounts from your primary?YesNoWhat is your gross total purchasing volume for all pharmacies?What is your current discounted cost of goods?DEA #What are your top 3 concerns?How did you hear about us?Does your business require licensing?YesNoPlease list licensesDate license issued? Date Format: MM slash DD slash YYYY License expiration date? Date Format: MM slash DD slash YYYY Description of Services/Products:Your Service Areas?Employer Identification Number (EIN):Date business first started? Date Format: MM slash DD slash YYYY Number of employees?Number of customers?Anything else we should know about your business? Please explain if so.APPA may run a company background check if necessary.* I understand Pharmacy Software ProviderInsurance ProviderWhat Marketing Are You Currently Doing?Do you have a marketing agency now? If so, who do you use?What are you looking to achieve from your membership?Please list any comments that will help us understand your needs. This iframe contains the logic required to handle Ajax powered Gravity Forms.
