Membership Application Firm Name*Name & Title of Representative to AAHP*Address*City*State*Zip*Country*Telephone*Email* FaxThere are three categories of membership: Voting Member Companies: includes corporate entities that operate a facility in the U.S. for homeopathic drug products (and when required, maintain a current FDA Establishment Registration Number) and that engage in one or more of the following activities in the U.S.: manufacturer, distribution or selling of homeopathic drug products. This is the majority of members and represents the core of the AAHP mission: promotion of excellence in homeopathic manufacturing, market development and appropriate regulatory oversight. Voting Members are required to maintain an active annual subscription to the Homeopathic Pharmacopeia of the United States (www.hpus.com). Affiliate Member Companies: includes corporate entities that do not meet the qualifications of a Voting Member, but are affiliated with or interested in the homeopathic industry. Examples include companies that provide services or consulting to the homeopathic industry, or foreign entities not marketing in the U.S., or educational institutions. Associate Member: includes people who possess an interest in homeopathy as it relates to manufacturing, distribution, marketing or selling homeopathic drug products. However, an individual member may not have a relationship with a member-eligible corporate entity, unless that corporate entity is already a member of AAHP and is represented by another person.Application for Membership Type:Voting Membership (please answer questions 1-24)Affiliate Membership (please answer questions 1-24)Associate Membership (please answer questions 19-25)1. Name of CEO/President2. Email (designated representative)Other email (others in firm to receive AAHP communications)Other email (others in firm to receive AAHP communications)Other email (others in firm to receive AAHP communications)Other email (others in firm to receive AAHP communications)3. Name / email of officer responsible for (one or more of the following):Regulatory AffairsEmailQuality AssuranceEmailManufacturingEmail3. Year Firm Established4. State/Country EstablishedIncorporated?YesNoPublic?YesNoPrivate?YesNo5. Specify the firm’s primary business activities (check all that apply): Manufacturing Distributing Research Service Provider Repackaging Marketing Consulting to Industry Other If Other, please explain6. Number of years firm has been manufacturing / selling homeopathic pharmaceuticals or providing consulting / service to homeopathic industry.7. Is the firm’s facility under the jurisdiction of the United States?YesNo8. Does the firm have an FDA Establishment Registration Number?YesNoIf yes, include a copy of FDA Establishment Registration.File9. State License Number10. If no Establishment Registration Number or State License, then Business License Number11. IRS EIN Number12. Does the firm have a proprietary line of homeopathic drug products that is marketed in the United States?YesNoIf yes, please list the trademark(s) under which the products are marketed13. Which of the following product types are manufactured or sold by the firm? (check all that apply) Single-ingredient homeopathic drug products Combination-ingredient homeopathic drug products Rx OTC Other If Other, please explain14. To which markets does the firm sell? (check all that apply) Natural Foods Export Mass Market Private Label Other If Other, please explain15. In which of the common dosage forms is the firm interested? (check all that apply) Tablets Liquids Topicals Ophthalmics Pellets Parenterals Nasal Sprays Other If Other, please explain16. Please include samples of five different representative homeopathic drug product labeling.Write samples here or attach below Drop files here or 17. Please include a product catalog or list showing all product names, label indications, and ingredients (may be an electronic file or link to webpage).Insert links or attach below Drop files here or 18. List all websites owned by company19. How did you become aware of or interested in AAHP?20. Briefly state the reason you wish to join AAHP.21. Of the 2-3 membership meetings each year, how many could you attend?22. List other homeopathic organization affiliations: National Center for Homeopathy Society for Ultramolecular Medicine State or regional homeopathic society (specify) Other homeopathic organization(s) (specify) Specify which state or regional homeopathic society / other homeopathic organization(s)23. What other business or professional organization(s) are you a member of or affiliated with?24. Please attach a profile (up to one page) of your company or homeopathic activities or interests. This profile will help all members become better acquainted with each other, and may be included in presentation materials about AAHP and its membership. File25. Associate members, please include a copy of your state pharmacist’s license (if applicable). In the event additional information is needed, a member of the Board of Directors will contact you.FileAmerican Association of Homeopathic Pharmacists Members’ Pledge Through our membership in the AAHP, we want to work with others to further the missions of the association: promoting excellence in the practice of homeopathic pharmacy, manufacturing, and distribution; providing opportunities for market development and market growth; maintaining an appropriate regulatory and legislative climate; providing outreach; promoting efforts to build a coalition with all interested parties within the homeopathic community. We support the AAHP by upholding the spirit and intent of the association’s Code of Ethics: supporting the Principle of Similars, the primary foundation of homeopathy; supporting the manufacture, distribution, marketing and sales of homeopathic drug products according to all applicable regulations; maintaining a level of professional competence by promoting training and education; respecting the values of competitors, and recognizing difference of viewpoint or philosophy; acting with honesty, integrity, and sincerity in all professional relationships; upholding the reputation, integrity, and growth of homeopathy in the United States; and using accurate information and fair balance to conduct our marketing activities. We wish to keep informed and continually educate ourselves and our staff of regulatory changes. Our company intends to work towards and maintain compliance with all applicable state and federal regulations for homeopathic drug products.Signature (Name) and DateVoting Member companies are required to maintain an active annual subscription to the Homeopathic Pharmacopeia of the United States (www.hpus.com).Membership DuesFor Voting Members, membership dues are based on self-reported annual sales.Sales Level: >$75 Million ||| Dues $60,000.Sales Level: $50-75 Million ||| Dues $55,000Sales Level: $30-50 Million ||| Dues: $38,500Sales Level: $20-30 Million ||| Dues: $29,300Sales Level: $10-20 Million ||| Dues: $18,700Sales Level: $5-10 Million ||| Dues: $13,400Sales Level: $3-5 Million ||| Dues: $9,000Sales Level: $1-3 Million ||| Dues: $6,500Sales Level: $600K-1 Million ||| Dues: $3,050Sales Level: $300-600K ||| Dues: $2,000Sales Level: <$300K ||| Dues: $1,000Affiliate Members$1,200Associate Members$200Please submit payments to: American Association of Homeopathic Pharmacists 4332 S.E. Logus Road Milwaukie, OR 97222 This iframe contains the logic required to handle Ajax powered Gravity Forms.