IAP Drug Formulary Payment Form

(*It is important that you provide an email & mobile number so that future communications can be sent to you via SMS/ e-mail)

Membership Type* :

Payment Category* :

Country* :

Title* :

First Name* :

Last Name :

Email* :

Mobile* : (10 DIGIT ONLY)

Postal Address * :

State* :

City* :

PIN/ZIP Code* :

Amount* :

* Amount is inclusive of GST.