NCPA-PDS Marketing Solution Center
Personal Information
  * Indicates a required field
* First Name:
* Last Name:
* Email Address: (i.e. you@domain.com)
* Pharmacy Name:
* Address Line 1:
  Address Line 2:
* City:
*State: *Zip: (i.e. 12345)
* Business Phone:  ( i.e. 123-456-7890 )
  Fax:  ( i.e. 123-456-7890 )
  Cell:  ( i.e. 123-456-7890 )
     
*
Yes, I am an NCPA Member. 
 
 
NCPA Membership Number:
    (If you don't have your number with you right now, we'll follow up with you later)
    I authorize you to charge the credit card below the NCPA monthly membership rate of $179 and a setup fee of $50.
* I am not an NCPA Member. I authorize you to charge the credit card below the NCPA monthly rate of $229 and a setup fee of $50.
  Yes, include text messaging for an additional $10/month.
   

This add-on includes the first 100 messages/month and then $.10 per message thereafter.

Certain features of the Marketing Solution Center are priced contingent per use. Included in your contract is 250 minutes per month for Voice Broadcasting, Free Recorded Messages, and the Testimonial Hotline with an additional fee of $0.10 per minute thereafter.
     
    Promotional Code:
 

 

Credit Card Information
    * Indicates a required field Total Charge Amount:
0.00
 
* Please indicate your Credit Card Type: 
Visa   Mastercard   American Express  
 
* Credit Card Number: 
 
* Expires:
 
* Security Code:
(i.e. 3 or 4 digit code found on the back of your card)
 
* Cardholder’s Name: 
(as shown on card): 
 
Billing Address: 
 Same as above
 
* Address Line 1: 
 
Address Line 2: 
 
* City: 
*State: *Zip: (i.e. 12345)

 

Terms and Conditions
  * Indicates a required field
   
*

I accept the terms and conditions. By accepting the terms and conditions, I authorize NCPAMarketing.com to automatically bill monthly the card listed as specified above. As noted above, I understand that additional fees may apply per use of specific Marketing Solution Center features. I also understand that I can end my subscription at any time by providing 10 days written notice , prior to the next billing cycle, to finance@ncpamarketing.com.

Recurring payments will occur approximately 30 days from original billing date.

This transaction will appear on your Credit Card Statement as: NCPAMarketing.com
 
* Name:
   (i.e. First & Last Name)
Date:
 05/21/12
 
     


GUARANTEE: If you're not totally satisfied, cancel within 30 days of signing up and receive a 100% refund.