ASHP 2013 National Pharmacy Preceptors Conference
August 21–23, 2013 I Washington Hilton Hotel I Washington, DC
Conference...
Conference Fees (Please check one.)
q	Full Registration Fee ASHP Member Non-member
Advance Registration (On or b...
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National Pharmacy Preceptors Conference

Published on: Mar 3, 2016
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Transcripts - National Pharmacy Preceptors Conference

  • 1. ASHP 2013 National Pharmacy Preceptors Conference August 21–23, 2013 I Washington Hilton Hotel I Washington, DC Conference Registration Form Registration Information (please type or print clearly) To guarantee member pricing, you must include your membership number below.   ❑  Check here if this is a new address. ASHP ID Number_________________________________________________________________________ Name_________________________________________________________________________________ Title _____________________________________________Name for Badge_________________________ Home Address___________________________________________________________________________ City/State/Zip___________________________________________________________________________ Employer/School (required)__________________________________________________________________ Employer/School Address___________________________________________________________________ City/State/Zip___________________________________________________________________________ Daytime Phone: ( _______ ) _______________________ Fax ( _______ ) ______________________________ Email addresses are required for confirmation of conference registration. Email (necessary for meeting confirmation)_______________________________________________________ ASHP does not sell or distribute email addresses of members, subscribers, or other customers. Mail confirmation to:   ❑ Home address  ❑  Business address Four Ways to Register ❑ Online at www.ashp.org/preceptors2013 (It’s the quick and easy way to go!) ❑ Call TOLL-FREE 1-866-279-0681, Mon–Fri, 8 am–6 pm EST International: 001-301-664-8700 ❑ Fax registration form to 1-301-657-1251 ❑ Mail registration form with check or money order payable to ASHP. (Checks must be drawn on a U.S. bank in U.S. funds.) Mail to: ASHP Payment Center P.O. Box 17693 Baltimore, MD 21297 What is your primary position? (check one) ❑ A Director ❑ B Associate or Assistant Director ❑ C Clinical Coordinator ❑ D Other Supervisory Position ❑ E Staff Pharmacist ❑ F Clinical Pharmacist— General ❑ G Clinical Pharmacist— Specialist ❑ H Community Pharmacy ❑ I Faculty ❑ J Student ❑ K Resident ❑ L Technician ❑ M Other: ______________ © 2013 American Society of Health-System Pharmacists® HPPRC113 FIRST                  MIDDLE                 LAST Important! Pre-conference registration closes August 9. All pre-registrations must be received by ASHP on or before that date. After August 9 registration for the National Pharmacy Preceptors Conference is ONSITE only. Method of Payment ❑ Charge to: ❑ MasterCard ❑ VISA ❑  American Express ❑ Discover Account #_____________________________________________ Expiration Date_________________________________________ Signature______________________________________________ ❑ Check or money order payable to ASHP attached. Checks must be drawn on a U.S. bank in U.S. funds. ❑ Purchase order #______________________________________ please issue an invoice. Register by July 12 for extra savings! Attendance is limited— register now!
  • 2. Conference Fees (Please check one.) q Full Registration Fee ASHP Member Non-member Advance Registration (On or before July 12) FM q $390 FN q $555 $ __________ Regular and On-site Registration (After July 12) FM q $450 FN q $665 $ __________ q Resident Fee (Pharmacy residents in ASHP- or Canadian-accredited programs) RM q $255 RN q $340 $ __________ q Pharmacy Technician Fee TM q $255 TN q $340 $ __________ q Student Fee (Full-time undergraduate or postgraduate pharmacy students) SM q $255 SN q $340 $ __________ Graduation date required to qualify for student fees: __________________ One-Day Registration Fees Please indicate which day(s) you will be attending. q Wednesday  OM q One Day, Member $340/day $ __________ _ q q ON q One Day, Non-member $460/day $ __________ Pre-Conference Workshops You must be a conference registrant and register by August 9 to attend workshops. Full day workshops include Breakfast, Lunch, and Break. Half day workshops include Breakfast or Break. 01WK Residency Learning System (RLS) (select one) q  $310 $ __________ _ Wednesday, August 21, 8:00 am–4:30 pm 01WKA ❑ PGY1 New Programs (Limited to the first 80 registrants) 01WKB ❑ PGY1 Existing Program (Limited to the first 100 registrants) 01WKC ❑ PGY2 New and Existing (Limited to the first 80 registrants) 01WKD ❑ Community Practice Residencies (CPRLS) (Limited to the first 25 registrants) 01WKE ❑ Managed Care Residencies (Limited to the first 25 registrants) 02WK Expanding Your Residency Program q  $160 $ __________ Wednesday, August 21, 8:30 am–11:30 am (Limited to the first 60 registrants) 03WK Principles of Practice-Based Education for Panicky Preceptors q  $160 $ __________ Wednesday, August 21, 1:30 pm–4:30 pm (Limited to the first 50 registrants) TOTAL FEES $ __________ © 2013 American Society of Health-System Pharmacists® HPPRC113 Registration Cancellations and Refunds To receive a full refund, confirmed registrations must be cancelled in writing on or before August 9, 2013 (postmark or fax date). Written cancellations postmarked or faxed August 10–August 16, 2013 will be subject to a $50 handling charge. Refunds will only be issued for cancellations postmarked or faxed before August 6, 2013. Customer service fax number is 1-301-657-1251. Thursday Friday

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