Pharmabridge Host 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 *

Institution/Organization

Name of Institution/Organization *

Area of Pharmacy Practice *

Areas of specialization in pharmacy practice *

Program Director *

Program Director/ Contact person Email address *

Institutional website *

City *

State/Province/District *

Country *

Areas of Pharmacy practice/Career development

What pharmacy practice training/course/ can you offer to Pharmabridge candidates? *

Can you provide onsite exchange program if the need arises? *

Do you have any specific requirement for enrolling in the course? *

What are your expectations from candidates? *

Any other information you choose to share? *

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 link a host/tutor/mentor/continuing education course to prospective candidates.

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)