NCPA Innovation Center/CPESN Community Pharmacy Fellowship Enrollment Form

NCPA Innovation Center/CPESN Community Pharmacy Fellowship Enrollment Form

NCPA Innovation Center is excited to start a new class of fellows. This fellowship program allows pharmacists to reach inside the minds and pharmacies of our best practitioners. Prospective pharmacies, please complete the following enrollment form carefully.
Pharmacy Information
Pharmacy Name*
Pharmacy NCPA Member ID Number*
Pharmacy Owner Name*

First NameLast Name
Pharmacy Phone Number*
Please enter a valid phone number.
Pharmacy Website
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pharmacy NCPDP*
Pharmacy NPI*
Primary Wholesaler*
Pharmacy Software Provider*

PioneerRxComputerRxLibertyRx30QS/1Other
Local CPESN Network
Who will be the Pharmacy Coordinator, providing oversight of the fellow and the program at the pharmacy?*

First NameLast Name
Pharmacy Coordinator Email*
example@example.com
Pharmacy Coordinator Mobile Phone Number*
Please enter a valid phone number.
Select the eCare Plan capable system provided to pharmacy employees.*
Why do you want your pharmacy to participate in the fellowship program?*
Fellow Information
Fellow Name*

First NameLast Name
Fellow Title
Fellow Email*
example@example.com
Fellow Mobile Number*
Please enter a valid phone number.
Which term would they like to join?*

October 2024 - August 2025
Select the date range that represents the year the fellow graduated from pharmacy school.*

20242023-20172016-2006Before 2005
Which statement best describes the fellow?*
Which time zone will the fellow be practicing in?*

Eastern TimeCentral TimeMountain TimePacific TimeAlaska TimeHawaii Time
Professional Headshot of the Fellow*

This should be a high resolution jpeg file of just the fellow in professional dress. It should not be a cropped photo from a group shot.
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Fellow Self-Assessment
Describe your community pharmacy experience: pre-pharmacy, internships, IPPE, APPE, and professional. This should include roles played (from janitor to technician to change agent). *
Describe any involvement with CPESN and/or Flip the Pharmacy up to this point in your career. *
Describe your experience working with and leading teams. *
Why do you want to participate in the fellowship and what do you hope to accomplish?*
Pharmacy Coordinator signs below to indicate they have reviewed the Fellow's Self-Assessment and discussed it with the Fellow. *

Clear
Pharmacy Coordinator Name*

First NameLast Name
Date

MonthDayYear
Date
Payment Information

Full tuition due is $7,500 and is nonrefundable.
*
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TuitionThis is a nonrefundable payment to reserve your spot in the fellowship class that counts towards the total tuition payment of $7,500
$7,500.00

Total

$0.00
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NCPA Innovation Center/CPESN Community Pharmacy Fellowship Enrollment Form

Pharmacy Information

Fellow Information

Fellow Self-Assessment

Payment Information