Community Connected Advisory Group
Name of the person completing the form:
*
First Name
Last Name
Your Title: (RPh., Technician, etc.)
*
Your email address:
*
example@example.com
Pharmacy Name:
*
Pharmacy NPI:
*
Select your State:
*
Please Select
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HA
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
To which ethnicity do you identify?
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
To which gender do you identify?
Male
Female
Other
Are you a pharmacy owner or part owner?
Pharmacy Owner
Part Owner
Other
Would you like to be a member of the Diversity Advisory Group?
*
Please Select
Yes
No
When would you like to meet?
*
Please Select
Monthly
Bi-weekly
Other (suggest times and dates for other)
Outline one or more specific objectives you would like this group to work on:
Outline a Mission statement? Goal? Vision? you would like to see for this group:
What are your concerns regarding diversity inclusion for CPESN USA?
What are your recommendations for this group?
Do you have a recommendation of someone who would be a good fit for this group? (Please provide their name, their email address and press save to add more.)
Submit
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