Alzheimer's/Dementia
Traineeship
Traineeship
Application
To
submit the Traineeship Application electronically, click
here to complete the online form and follow the instructions
as specified. You may also submit the form by postal mail by
following the directions located at the bottom of this form.
| Name |
| Employer/Company
Name |
| Preferred
Mailing Address |
| City,
State, Zip |
| Telephone |
Fax |
E-mail
|
TRAINEESHIP DATE: The traineeship will take place October 27-31, 2008.
ADDITIONAL
APPLICATION DOCUMENTS REQUIRED:
The
following items are to be appended to this
form, each clearly labeled in the upper
right-hand corner, as indicated (Exhibit A, Exhibit B, Exhibit
C):
Exhibit
A. Curriculum vitae, which must include the applicant's
education, experience record in pharmacy practice (in reverse
chronological order, most recent first), and any relevant publications,
presentations,
and community service.
Exhibit
B. A statement of not more than three typed, double-spaced
pages describing (1) why the applicant wants to participate
in the traineeship
and the applicant's expectations of the traineeship experience;
(2) nature and extent of professional or personal involvement
with persons with Alzheimer's disease or related dementias,
caregivers, or family members; (3) current level of clinical
services provided by the applicant, including total number
of
patients served, geographic distribution (urban, rural, suburban),
ethnic distribution (Black, White, Hispanic, Asian/Pacific
Islander,
American Indian/Eskimo/Aleut), and number of patients with
Alzheimer's disease or related dementias; (4) special services
or programs
provided by the applicant; (5) how the traineeship will enhance
the pharmacy services currently provided; and (6) how the results
of the traineeship experience will be incorporated into the
applicant's practice.
Exhibit
C*. A letter from the applicant's employer confirming
support for the applicant's participation in the traineeship
and willingness
to implement the results of the traineeship. The letter should
be addressed to the applicant and signed by the chief
executive
officer, director of pharmacy, clinical coordinator, or other
appropriate manager/supervisor in the organization.
*If the applicant is self-employed, this exhibit may be omitted.
