Pharmacist Community Ambassadors Sign-up
*
indicates required
Name:
Email:
Comment:
Email Address
*
First Name
*
Last Name
*
Phone Number
Zip Code
*
Website
Have you recently recieved flu training?
Yes
No
If yes, then where did you receive that training?
School/Continuing Education
Work/On-the-job traning
Networking Group
CDC
I have not received training.
