June 15, 2023 CEU Form Name First Last Street Address* City* State* Zip* Phone*Email* Employer* 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*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 Δ
