* 1. Name:

* 2. Email:

* 3. Phone number:

* 4. Please indicate your availability to work in the ACE Lab for cleaning, monitoring, and program setup for a typical week during the Spring 2017 semester (beginning in March) - Check all that apply

* 5. Please indicate your availability to work in the ACE Lab for occasional cleaning, monitoring, and program setup during the summer break (May - mid August) - Check all that apply

* 6. Please indicate your availability to work in the ACE Lab for cleaning, monitoring, and program setup for a typical week during the Fall 2017 semester - Check all that apply

* 7. Do you have any prior compounding (non-sterile or sterile) compounding experience beyond pharmacy school lab experience?   If so, please briefly describe your experience.

* 8. What are your future career plans and interests?

* 9. Please provide a brief personal statement indicating why you should be chosen for this internship position.  (250 words or less)

* 10. Please provide one professional reference (employer/supervisor, teacher, etc.)

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