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.
