Pharmacy Awareness Month 2019 Pin Request Form
Disclaimer
Our PAM 2019 pin collection has been in collaboration with CSHP-AB. Therefore, in an attempt to ensure as many of our members receive the quantity requested. Please ensure only 1 request is being sent in for your pharmacy location. Pins will be distributed on a first come, first served basis. Selection of pins mailed out will be based on availability and equal selection distribution based on amount being requested.

Each order comes with 1 pin of each of the 4 designs. Which means "Quantity Needed = 1" means you will receive 1 order of 4 pins.

NAME (FIRST and LAST)
Your answer
EMAIL ADDRESS
Your answer
MAILING ADDRESS
Your answer
PTSA MEMBERSHIP NO.
Your answer
QUANTITY NEEDED
Your answer
Is the requested quantity for your entire staff pool? If no, which pharmacy professional category is this quantity being requested for?
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service