CAPE Reviewer Interest Form

Please provide us with the following information:

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* 1. First Name

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* 2. Middle Name

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* 3. Last Name

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* 4. Suffix (i.e., PharmD, PhD, MS, etc.)

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* 5. Title

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* 6. Organization Name

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* 7. Mailing Address

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* 8. City

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* 9. State

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* 10. Zip Code

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* 11. Phone Number

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* 12. Email Address (Please note that materials are sent to reviewer via email.)

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* 13. What is your professional background? (Check all that apply.)

Pharmacist

Pharmacy Technician

Other (please specify)

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* 14. What is your workplace setting?

Academia

Administration

Community/Ambulatory Care

Hospital/institution

Other (please specify)

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* 15. How many years of experience do you have in the workplace setting mentioned above?

1 - 3 years

4 - 6 years

7 - 10 years

10+ years

More than 1 (one) workplace setting (please specify)

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* 16. Please disclose any conflicts of interest. (Please enter N/A, if you have no conflict of interest.)

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* 17. Why are you interested in becoming a CAPE reviewer?

Thank you, your response is greatly appreciated.