Pharmabridge Candidate registration form

Demographics

First Name *

Family Name/Last Name *

Address Line 1 *

Address Line 2 (optional)

City *

State/Province/District (optional)

Postal Code *

Country *

E-mail Address *

Telephone *

Note: Enter a phone number in this format: +[Country Code]-1234567890

Professional

Professional Status *

Area of Pharmacy Practice *

Any specific area of specialization in pharmacy practice *

Institution/Institutional Affiliation *

Organization/Place of Work *

Career Needs and Areas of Development

What is your central career focus/goal? (This could be a short- or long-term goal) *

Career needs (a short description of your professional educational needs) *

Do you have any specific course you want to learn? *

Do you have any career offers already? *

Do you require a mentor? *

Yes No

In what area of pharmacy do you need a mentor?

What are your expectations? *

Are you aware of the FIP-Continuing Professional Development learning platform? *

Yes No

Pharmabridge

How did you get to know about the Pharmabridge program?

LinkedIn: FIP-Pharmabridge
LinkedIn: FIP, FIP-Foundation, ECPG
Other LinkedIn pages
Websites: FIP, FIP-Foundation, ECPG
Newsletters: Pharmabridge, FIP-Foundation, FIP, ECPG etc
Colleagues

Consent

I understand that my registration is used by Pharmabridge program to find me a suitable host/tutor/mentor/continuing education course and that my information can be sent forward to the host/tutor/mentor/education provider for evaluation.

I give the right to Pharmabridge to save my information to the Pharmabridge database.

Yes No

I want to receive the Pharmabridge Newsletter (You can unsubscribe at any time)

Pharmabridge Candidate registration form

Demographics

Professional

Career Needs and Areas of Development

Pharmabridge

Consent

Partners

FIP works for