Application for Corporate Membership

ORGANIZATION INFORMATION


RELATIONSHIP WITH ROUNDTABLE MEMBER(S)

* 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 membership guidelines require each Corporate Associate Member to be sponsored by an active Roundtable member. An original signature is not required.

Office Use Only