CORE: NCPA Leadership Program Enrollment Form

CORE: NCPA Leadership Program Enrollment Form

Through our Change, Optimize, Revitalize, and Energize methodology, CORE empowers you, your team, and your business to operate and grow successfully. The key to thriving amidst challenges lies in what you can control. CORE helps you harness that control and drive meaningful change within the fundamental areas of your business. Please complete the following enrollment form carefully.
Your Name*

First NameLast Name
Your Position*
Your Email*
example@example.com
Your Mobile Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
MyselfEmployee
Employee Name (whoever will be participating in CORE)

First NameLast Name
Pharmacy Name*
Pharmacy Owner*

First NameLast Name
Pharmacy NCPA Member ID Number*
Pharmacy Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Pharmacy Website
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Local CPESN Network
Select the eCare Plan capable system provided to pharmacy employees.*
Primary Wholesaler*
Pharmacy Software Provider*
20252017-20242006-2016Before 2005
Eastern TimeCentral TimeMountain TimePacific TimeAlaska TimeHawaii Time
Professional Headshot

High resolution files are preferred.
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Why do you want to participate in CORE and what do you hope to accomplish?*
Describe your experience working with and leading teams. *
Your Signature*

Clear
Date*

MonthDayYear
Date
Payment Information

The exclusive introductory rate for the inaugural cohort is $699 per month, a monthly savings of $200 off our regular rate of $899 per month. Participants can choose to make monthly payments or pay an upfront, further discounted rate of $8,000. Tuition for the program is nonrefundable. Enrollment in the program constitutes a 12-month commitment, with the option to renew thereafter. You will not be automatically renewed or charged beyond that commitment without your consent. *We recommend creating a PayPal account when you submit payment, in the event you need to update your payment method in the future.*
Payment Options*
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CORE - Discounted, Annual Payment Option
Save an additional $388 when you pay for the entire year upfront.

$8,000 for each year

CORE - Monthly Payment Option
Total payments over the course of the year will equal $8,388.

$699 for each month
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CORE: NCPA Leadership Program Enrollment Form

Payment Information