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 CPESN members 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 Name Last Name
Pharmacy Phone Number *
Please enter a valid phone number.
Pharmacy Website
Address *

Street Address

Street Address Line 2

City State / Province

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

PioneerRx ComputerRx Liberty Rx30 QS/1 Other
Local CPESN Network *
Who will be the Pharmacy Coordinator, providing oversight of the fellow and the program at the pharmacy? *

First Name Last 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? *
Payment Information

Full tuition payment of $7,500 is due when the Terms and Conditions is executed by the pharmacy. You will receive the Terms and Conditions after the Enrollment Form is submitted.
Payment Method *

Check Credit Card
In order to pay your tuition via a checking account, provide the following information to your bank:

Bank Name: SunTrust Bank

Bank Address: 1 Park Place Atlanta, GA 30303

ABA Routing No: 061000104

Beneficiary Acct No: 1000195670285

Beneficiary Name: NCPA Innovation Center

Please make a note where possible that the payment is for "Fellowship Tuition".

Tuition payments are due once you sign the terms and conditions with NCPA. A copy of this agreement is included in your confirmation email once you submit your enrollment form.
Credit Card Type *
Credit Card Number *
Expiration Date *

Month Day Year
Date
Security Code (Security code is the three-digit number on the back of credit card or the four-digit number on the front of American Express card.) *
Authorized Signature/Name on Card *

Clear
Authorized Signature Name/Name on Card *

First Name Last Name
Date *

Month Day Year
Date
Fellow Information
Fellow Name *

First Name Last Name
Fellow Title
Fellow Email *
example@example.com
Fellow Mobile Number *
Please enter a valid phone number.
Select the date range that represents the year the fellow graduated from pharmacy school. *

2021 2020-2016 2015-2005 Before 2005
Which statement best describes the fellow? *
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.
Cancel of
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 Name Last Name
Date

Month Day Year
Date
Should be Empty:

NCPA Innovation Center/CPESN Community Pharmacy Fellowship Enrollment Form

Pharmacy Information

Payment Information

Fellow Information

Fellow Self-Assessment