Application for Corporate Membership ORGANIZATION INFORMATION ORGANIZATION PRINCIPAL CONTACT MAILING ADDRESS CITY STATE ZIP CODE RELATIONSHIP WITH ROUNDTABLE MEMBER(S) ROUNDTABLE MEMBER* RELATIONSHIP * Roundtable membership guidelines require that Corporate Associate Members must provide a service to one or more Roundtable members. Please identify the Roundtable member with whom you are engaged and the nature of the relationship (i.e. PBM, Consultant, Plan Administrator, etc.). SPONSOR ROUNDTABLE MEMBER** SPONSOR'S NAME DATE **Roundtable membership guidelines require each Corporate Associate Member to be sponsored by an active Roundtable member. An original signature is not required. Office Use Only APPROVAL VOTE MEMBERSHIP DATE
