Person Requesting Approval (Last Name, First Name) *
Email Address *
Phone Number (inlcude area code) *
Activity Requested *
If other was selected in Question #4, please specify activity (please provide any needed explanation of event if not a presentation, shadowing, or interview experience):
Date Occuring *
Time event occurring *
Location of event *
Name of Pharmacist Speaker
Work place of Pharmacist
Job position of Pharmacist *
(i.e. Residency Director, Corporate Management, Staff Pharmacist, etc)
List Career Area of Pharmacist if group activity involves a speaker
i.e. Community Pharmacy, Patient Centered Medical Home, etc
Sponsoring Student Organization (if applicable)
Who will pick up the parking pass for the career mentor & what date would you like to pick it up?
Upload any mock ups of flyers/advertisements that need to be approved by Dr. Grant.
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