INTERNATIONAL PHARMACISTS ANONYMOUS - Membership Form
Please copy and distribute freely
IPA is a Fellowship of Pharmacists-in-recovery who share their Experience, Strength and Hope with each other to help solve their common problems and help other pharmacists and pharmacy students recover from addictive disease.  It is a supplement, not substitute, for regular 12 step meetings. We share with newly recovering pharmacists, & students who feel isolated, unique, unworthy and hopeless that there IS hope. The only requirement for membership is a desire to find and maintain recovery
NO DUES OR FEES REQUIRED - But donations for administrative and Website costs are always welcome and appreciated.

Please print legibly or type all requested information and sign this form prior to mailing.
Name: ________________________________   Sex: ______   Birthdate: M____D_____Y__________
Address: ____________________________________________________________
City____________ State____ Zip/Postal Code_________      Country___________
E- mail_____________________@_______________________________. We usually correspond by e-mail.
May we correspond with you (e.g., information/newsletters) at this e-mail address? Yes___No____
I prefer to receive IPA correspondence by mail and agree to pay the costs of such mailings Yes___No____
I can be reached at these phone numbers: (Can you speak freely there?)
Home:  (        ) _____________________      Yes ____    No ______   Fax (____)_____________
Work:   (        )_____________________       Yes ____    No ______
Cell or page(____)____________________  Yes ____    No ______
12 Step Affiliation:  AA ___  NA ___  GA ___ Al-Anon ___ Other (specify) ________________
How did you hear about IPA? ______________________________ (e.g., journal, person, agency, group)
Willing to help another Pharmacist?  Yes___ No____ . 
May we share your contact information with other members wishing to contact members in your area?Yes__No__
Your practice(s) and specialty(s): _______________________________(e.g., community, hospital, industry)
Degree(s):  BS___  MS/MA___  PharmD___  PhD___  MD___  Student___  Other (specify) ______________
If Student, target degree/expected graduation date:  ________ Did you recover as a student?_________
RPh License History:   Current ___ Revoked ___ Reinstated ___ Probation____ RX Student now _____
Signature:  _______________________________________________________Date: _________________
Optionals:  Any restrictions you request for listkeepers or secretary making contacts?_____________________________
Offer to share: (e.g., language, prison or DEA exp. orientation, job with no license) ______________________
Sober/Clean date: _________________earlier dates?__________________________ 
Significant other (name):__________________________________
Questions/Comments, notes for newsletter (use back too)____________________________________
Print, complete, and mail (please do not e-mail) application to:
  Jim Alexander, Co-Listkeeper, 5100 Emerson Av So, Minneapolis, MN, 55419-1156.
     Ph. 612/825-5533.  e-mail JAlexa1876@aol.com . Alternative contacts if Jim Alexander cannot be reached:
 Jeff Baldwin, Co-Listkeeper, Ph. 402-493-2384 h or 402-559-6498 w. e-mail jbaldwin@unmc.edu
 Emily Dykstra, Secretary, Ph. 877-890-4776. e-mail emily@proheights.com
                                   Please keep a copy of the application for reference for IPA contact information.