SESSION
PREFERENCE: Preferences
will be taken into consideration, but cannot
be guaranteed. Submission of an application indicates
an ability to attend either traineeship session.
(Selection required.)
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, including 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
Parkinson's disease and other neurological disorders,
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 Parkinson's disease; (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.
