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.
