2023 Guardian Symposium CEU form Fri May 19 Name First Last Street Address* City* State* Zip* Phone*Email* Profession Type*Pharmacist/Pharmacy TechNurseAdministratorLicense Number*FL CPh’s – please include PS and PU Would you like your hours reported to NABP?* Yes No For pharmacists/pharmacy techs*If you’d like your hours uploaded to CPE Monitor, please include your NABP number and DOB (mm/dd) Would you like your hours reported to NAB?* Yes No 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 Pharmacists*To which license do you want hours for Block 1 applied? PU PS NA Pharmacists*To which license do you want hours for Block 2 applied? PU PS NA Δ
