NCPA Innovation Center/CPESN Community Pharmacy Fellowship Enrollment Form

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*

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 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?*

April 2023- March 2024September 2023 - August 2024

Select the date range that represents the year the fellow graduated from pharmacy school.*

20232022-20162015-2005Before 2005

Which statement best describes the fellow?*

Which time zone will the fellow be practicing in?*

Professional Headshot of the Fellow*

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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.

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

*

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