2024 Senior Care Conference CEU Form Day 1

Name
First Last
Street Address*
City*
State*
Zip*
Phone*
Email*
Profession Type*
License Number*
FL CPh’s – please include PS and PU
For pharmacists/pharmacy techs*
If you’d like your hours reported to NABP, please provide your profile number here
Date of Birth (MM/DD)*
Please provide DOB in MM/DD format
For nursing home administrators*
If you’d like your hours reported to NAB, please include your NAB profile number here (ex. R12345)
Are you licensed in state(s) other than FL?*
- Yes
- No
Consultant Pharmacists*
If you are licensed in FL as both a CPh and RPh, to which license do you want hours applied for Session 1A and 1B?
- PU
- PS
- N/A (I do not have a CPh license)
Consultant Pharmacists*
- PU
- PS
- N/A (I do not have a CPh license)
If you are licensed in FL as both a CPh and RPh, to which license do you want hours applied for Session 2A, 2B and 2C?

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