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* 1. First Name

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* 2. Last Name

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* 3. Email address

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* 4. Phone Number

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* 5. Enter the Name of Your Practice Site

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* 6. Enter the City Where You Practice

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* 7. Nebraska DHHS requires a Memorandum of Understanding from each participant that if the course work is not completed in the allotted time, the participant must reimburse the registration and program fees of $115.00 to the Nebraska Pharmacists Association by February 1, 2021.

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