CEU Form Saturday, 6-17-23

Name
First Last
Street Address*
City*
State*
Zip*
Phone*
Email*
Employer*
Profession Type*
License Number*
FL CPh’s – please include PS and PU
Would you like your hours reported to NABP?*
- Yes
- No
For pharmacists/pharmacy techs*
Please include profile ID and DOB (mm/dd). Hours will NOT be reported if BOTH numbers are not recorded here.
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

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