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General Information

First Name:*

MI: Last Name:

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Please select Profession(s): *

Faculty
Other
Pharmacist
Pharmacy Technician
Staff

NABP/ACPE ID Number:

License #:

Date of Birth:*

Company Name:

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Billing Address 2:

Country: *

State: *

City:

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Profile Questionnaire

What is your affiliation? *

UNC Faculty, Staff, Trainee or Student
Resident
Other

What is your current residency year? *

PGY1
PGY2

What is the name of your Residency Program Director?

What is the location of your residency (e.g., UNC Hospital)?

Are you in the Resident Teaching Certificate Program? *

Yes
No

Where are you visiting from?

What is your primary UNC campus? *

Asheville
Chapel Hill

What is your current position? *

What is your current track? *

Tenure
Clinical
Research
Adjunct

What is your current rank? *

Professor
Associate Professor
Assistant Professor
Instructor

Please identify your current position.

What is your current program of study? *

PhD
PharmD
Masters
Other

What is your current program of study? *

OR Don't know

With which UNC school are you affiliated? *

What is your primary UNC school affiliation?

Please identify your division in the School of Pharmacy. *

What is your primary department/unit/center?

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