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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 |
| Degrees(s) |
| Employer/Company
Name |
| Preferred
Mailing Address |
| City,
State, Zip |
| Telephone |
Fax |
E-mail |
SESSION
PREFERENCE: Preferences
will be taken into consideration, but cannot be guaranteed.
Submission of an application indicates an ability to
attend either traineeship session. Please check:
|
June 7-11 |
|
October 18-22 |
|
No preference |
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 acute or chronic pain conditions;
(3) current level of clinical services provided by the applicant,
including total number of patients served, geographic distribution
(urban, rural, suburban), and ethnic distribution (Black, White,
Hispanic, Asian/Pacific Islander, American Indian/Eskimo/Aleut);
(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 or affiliated
institution or organization confirming support for the applicant's
participation in the traineeship and willingness to implement
the results of the traineeship experience. 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 institution or organization.
*If
the applicant is self-employed, this exhibit may be omitted.
I
certify that the information I have submitted in this application
and the accompanying exhibits are complete and correct to the
best of my knowledge and belief.
If submitting by mail, send the completed application form
and attachments to: ASCP Foundation, 1321 Duke Street, Alexandria,
VA 22314.
Deadline
for Receipt of Applications: March 31, 2010.
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