SESSION
PREFERENCE: Every effort will be made to accommodate session
preferences for the applicants selected for participation, but
preferences cannot be guaranteed. Submission of an application
indicates an ability to attend either traineeship session.
|
June
23-27 |
|
September
22-26 |
|
No
preference |
ADDITIONAL
APPLICATION DOCUMENTS REQUIRED:
The following items of information 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.
