Individual Membership/ Foundation Donation Form 
 
 
 
 

Please note that membership applications may also be made directly on the Internet at https://www.fip.org/www2/membership/registration.php 

Title:   ________    First name:   ________________________________________________   
 

Middle name(s)    _______________________ Last name: __________________________

or initial(s):

Company:    ____________________________________________________________ 
 

Billing Address:    ____________________________________________________________ 
 

____________________________________________________________ 
 

               ____________________________________________________________ 
 

Country of Residence:   _________________________  _______________________ 
 

Tel. number:     ________________________  Fax number:  _______________________ 
 

E-mail address:    ___________________________________________  Sex (M/F):  ______

Date of birth (dd/mm/yy): ______/______/______Graduation year (first degree): ________ 
 

Payment Details (please tick appropriate box and complete form) : 

• Cash  
  
• By credit card:

Visa  ¡     Amex ¡ Master/Euro card  ¡ 

      CVC (obligatory for VISA and Master/Euro card)   ........................

 
Card number:

                     .................../ .................. /.............../...................../

 
Expiry date             [.........../...........]    [Month / Year]  

Individual Membership (*Category list attached)  _______________

• Category A €  90
• Category B €  54 
• Category C €  33 
• Student (entitled to a 50% discount on the total membership fee)

FIP Section Membership (one section is included in the basic membership fee; additional sections are  €16 each)

• Academic Pharmacy   _______________

• Administrative Pharmacy   _______________

• Clinical Biology    _______________