NCPA Innovation Center/CPESN Community Pharmacy Fellowship Enrollment Form

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? *

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. *

2022 2021-2016 2015-2005 Before 2005

Which statement best describes the fellow? *

Which time zone will the fellow be practicing in?

Eastern Time Central Time Mountain Time Pacific Time Alaska Time Hawaii Time

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 Name Last Name

Date

*

Reservation Fee This is a nonrefundable payment to reserve your spot in the fellowship class that counts towards the total tuition payment of $7,500

$ 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