24th Annual Pharmacy Practice Seminar Registration Form (Printable)
Register Online at : http://pharmapp.pharmacy.unc.edu/continuing/onlinereg/ or Complete this form and forward to Krista Williams, 919.843.6769(fax) or krista_williams@unc.edu
REGISTRATION FORM (To register online: http://pharmapp.pharmacy.unc.edu/continuing/onlinereg/)
Please list one person per registration form.
Name __________________________________________ ID # xxx-xx- ___________ (last 4 digits of SSN)
Business/Practice Site (for nametag) ________________________________________________________
Mailing Address ________________________________________________________________________
City State Zip _____________________________________________ County ______________________
Daytime Phone # __________________________ email ________________________________________
** DISCOUNT FOR EARLY REGISTRATION ** Postmarked by 08/19/2009
| Choose: Sat or Sun | Reg. Rates for ONE DAY: | Reg. Rates for TWO DAY: | List Total Amount |
| Pharmacists | $140 | $250 | $ ___________ |
| Students Residents Technicians | $ 40 | $60 | $ ___________ |
| Certificate Program Attendee Special* | $110 | $180 | $ ___________ |
| Register / postmark by 8/19/09 Subtotal | $ ___________ | ||
| Register / postmark after 8/19/09 and add $50 to the Subtotal amount | $ ___________ | ||
| Total Amount | $ ___________ |
[*See section below to register for the Pharmacy-Based Immunization Delivery Certificate Program]
3 Payment Methods: Pharmacy Practice Seminar 2009
(1) Visa/Master Card Only Credit Card # ______________________________________________________
Expiration date:____________ Print name as it appears on card: _________________________________
Signature (required for credit card transactions): _______________________________________________
Fax: 919.843.6769 CE Office, UNC Eshelman School of Pharmacy – OR –
Mail to: CE Program UNC Eshelman School of Pharmacy, CB# 7574 Beard Hall, Chapel Hill NC 27599-7574. (2) Check Enclosed $ _______ (make checks payable to Pharmacy Practice Seminar)
Mail to: CE Program UNC Eshelman School of Pharmacy, CB# 7574 Beard Hall, Chapel Hill NC 27599-7574. (3) Register Online at: www.pharmacy.unc.edu/continuing/onlinereg (preferred method)
Indicate Sunday workshop choices for a total of 3.0 contact hours CE Credit. Please list by number your top 4 choices with #1 being your first choice:
____ A. What to Expect from the Inspector… (1.5 hrs)
____ B. Spanish for Pharmacists (1.5 hrs)
____ C. Drugs of Abuse for 2009 (1.5 hrs)
____ D. Pens and Needles (1.5 hrs)
____ E. New Drugs1.5 hrs)
____ F. Interpreting Lab Values (1.5 hrs)
Pharmacy-Based Immunization Delivery Certificate Program 9/11/09
Yes, I have CPR Certification. Exp. Date ______________
OR
I will take a CPR Certification course on __________________ (date).
** The Immunization Certificate of Achievement is not valid until CPR is obtained or current.
Note: All participants are responsible for obtaining provider level CPR certification.
Immunization Certificate Program Registration Fees: $350 per participant
3 Payment Methods: Immunization Certificate Program
(1) Visa/Master Card Only Credit Card # ________________________________________________________
Expiration date:____________ Print name as it appears on card: _________________________________
Signature (required for credit card transactions): _______________________________________________
Fax: 919.843.6769 CE Office, UNC Eshelman School of Pharmacy – OR –
Mail to: CE Program UNC Eshelman School of Pharmacy, CB# 7574 Beard Hall, Chapel Hill NC 27599-7574.
(2) Check Enclosed $ _______ (make checks payable to Immunization Certificate Program)
Mail to: CE Program UNC Eshelman School of Pharmacy, CB# 7574 Beard Hall, Chapel Hill NC 27599-7574.
(3) Register Online at: www.pharmacy.unc.edu/continuing/onlinereg
OTC Advisor: Advancing Patient Self-Care
Registration Fees: $350 per participant
3 Payment Methods: Immunization Certificate Program
(1) Visa/Master Card Only Credit Card # ________________________________________________________
Expiration date:____________ Print name as it appears on card: _________________________________
Signature (required for credit card transactions): _______________________________________________
Fax: 919.843.6769 CE Office, UNC Eshelman School of Pharmacy – OR –
Mail to: CE Program UNC Eshelman School of Pharmacy, CB# 7574 Beard Hall, Chapel Hill NC 27599-7574.
(2) Check Enclosed $ _______ (make checks payable to Immunization Certificate Program)
Mail to: CE Program UNC Eshelman School of Pharmacy, CB# 7574 Beard Hall, Chapel Hill NC 27599-7574.
(3) Register Online at: www.pharmacy.unc.edu/continuing/onlinereg
Questions: Krista Williams, Executive Manager
UNC Eshelman School of Pharmacy
Continuing Education
919.843.4028 krista_williams@unc.edu