Free 50689.FH11 - Indiana

INDIANA BOARD OF PHARMACY CONTINUING EDUCATION (C.E.) APPLICATION
State Form 50689 (R / 2-06)

INDIANA BOARD OF PHARMACY PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, IN 46204 Telephone: (317) 234-2067 E-mail: [email protected]

TYPE OF PROGRAM Seminar Professional Meeting Home Study Teleconference CD-ROM Video School of Pharmacy Program

Post-Graduate Course Other (explain):

Name of applicant

Address (number and street, city, state, and ZIP code)

Telephone number

(
Program sponsor E-mail address

)

Program title

Location of program

Date of program (month, day, year)

Contact hour(s) of the course (A contact hour is equivalent to 50-60 minutes of organized learning experience.)

Method for evaluating the program

Web address

Please attach a copy of the speakers curriculum vitae, a description of expertise, or other documentation regarding speakers expertise on topic.
Name of speaker

Title of speaker

Telephone number or e-mail address

INSTRUCTIONS: 1. Please attach the following items to this application: An agenda documenting the hours of organized learning experience. Any supplementary materials: (for example, program outlines, hand-out materials, self-assessment questions, course contents, bibliographies, etc.) A copy of the speakers curriculum vitae, a description of speakers expertise, work history or other documentation regarding the speakers expertise on the topic. Three (3) topic / presentation specific learning objectives for the program. 2. Please do not submit attendance rosters. The sponsor must retain these for 48 months and provide each participant with a certificate using the number provided and the program title. 3. Applicants seeking credit for graduate level courses will be considered for credit upon the applicant providing: Proof of successful completion of the course. A course description from the college catalogue. Examples of the topics covered in class. Note: Pharmacy student (PharmD candidate) presentations will no longer be accepted for Indiana continuing education hours. Please return to: Indiana Board of Pharmacy Professional Licensing Agency 402 West Washington Street, Room W072 Indianapolis, IN 46204 Telephone: (317) 234-2067 E-mail: [email protected]