MEMBERSHIP APPLICATION

PHARMACY FRANCHISE OWNERS ASSOCIATION

Membership as a regular voting member is open to all persons owning and
operating a pharmacy franchise in good faith, including sole proprietors,
partnerships, corporations, and limited liability companies. Specific membership
requirements are set forth in the Bylaws of the Association.

Store number(s)                                                                      Date                            

Owner’s Name                                                                                                             

Address                                                                                                                        

City                                                                        State              Zip                           

Are you a multi-store owner? (  ) Y (  ) N

If yes, please list stores individually

    Store#                  DEA#                        NPI#                PHONE#         FAX#

E-mail (medicineshoppe.com addresses are not allowed)

                                                                                  

I certify I am a pharmacy franchise owner/operator as explained above and
qualify for membership in this Association and will abide by the Bylaws of the
Association as they may be amended from time to time. I further understand
the current initial membership fees are One Thousand Dollars ($1000.00) per
unit, which shall be deemed to be pre-paid fees for membership services to
be provided by the Association. The corporation will keep accurate records
of the cost of services provided to members and will notify to members at least
annually of the portion of such fee which has been earned by the Association.
 

Annual fees are not currently assessed and there are no current plans to do so.
The Board of Directors has the right to assess annual fees in the future, but
members would not be required to pay them unless they wanted to continue
active participation in Association programs and services. Additional optional
programs may be made available from time to time that may have a separate fee.

Signature                                                                      Check No.                           

• Make checks payable to “Pharmacy Franchise Owners Association.”  Please mail checks to:

Pharmacy Franchise Owners Association

11674 Baptist Church Road

St. Louis, MO 63128

• Bill my credit card in twelve (12) monthly payments of $83.34 for the total Membership fee of $1000.00.