Become a Member – Private Pharmacy Retail Business Association

Membership Registration Form

Become a Member

This form is primarily meant for Pharmacy Business Owners in Trinidad & Tobago who would like to apply to become a member of the Private Pharmacy Retail Business Association (PPRBA).

Applicant Information

Business Owner First Name

Business Owner Middle Name

Business Owner Last Name

Business Name (as Registered)

Business Address (Street, City, Country)

Address Line 1

Address Line 2

City

Country

Contact Phone Number

Email Address

Password (To be able to sign into this website to access membership documents when approved)

License Information

Name of Licensing Pharmacist

Is the Responsible Pharmacist the Business Owner

Yes

Pharmacy Business Details

Business Entity Type

Other (Please Specify)

Number of Years in Operation

Branch Information (if applicable)

Are there other Brances of your Pharmacy?

Yes

Branch 1 Name

Branch 1 Address

Branch 2 Name

Branch 2 Address

Branch 3 Name

Branch 3 Address

Branch 4 Name

Branch 4 Address

Branch 5 Name

Branch 5 Address

Branch 6 Name

Branch 6 Address

Membership Information

The monthly membership contribution for the Pharmacy Business Owners is $100.00 TTD. Payment details is in the "Payment Information" section below.

Members eligibility for voting and serving on the executive:

Only paid members are allowed to vote
Pharmacists and Business owners must have a minimum of seven (7) years’ experience to serve on the executive

Payment Information

Company Name: Private Pharmacy Retail Business Association
Bank: First Citizens Bank
Account Number: 3174483
Type: Chequing

Declaration

By submitting this application, I affirm that the information provided is accurate to the best of my knowledge. I understand that membership in PPRBA is subject to approval and I agree to abide by the association's By-laws and Code of Conduct. Please check the box if you agree.

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Membership Registration Form

Applicant Information