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Ownership Workshop Registration

* Denotes required information.



NCPA Member Number:
Title:	Mr. Mrs. Ms. Dr.
* Full Name:
Suffix:

* Pharmacy Name:
* Address:
* City:
* State:
* ZIP:
* Telephone:
Fax Number:
* E-Mail:

Tell Us...
Please check all that apply. Describe your current employment plans: I am a ________ pharmacy owner. sole partner stockholder I am planning to buy an existing pharmacy in years. I am planning to start a new pharmacy in years. If buying or starting a pharmacy, how do you plan to finance it? Financial lending institution Small Business Administration loan Borrow from a relative/friend Finance through the seller Finance/borrow from a wholesaler or buying group Other What services/programs do you or will you provide? Home health-care products (canes,walkers, etc.) Home infusion therapy Pharmacy consultant services to institutions (nursing homes, assisted-living facilities, etc.) Private label products Conduct physician detailing Home or office delivery Compounding services Pharmacist care and health screening services: Diabetes Asthma Osteoporosis Immunizations OTC counseling Lipid management Weight loss/nutrition Anti-coagulation mgmt. Other Describe your pharmacy location? Urban (>50,000 pop.) Rural ( Medical Center/Clinic Suburban City Residential Area Shopping Center How would you describe your current pharmacy employer? Professional Shop Traditional Community Retail Chain Institutional Other How many years has the pharmacy where you are employed been in business at this location? years How many hours is the pharmacy where you are employed open each week? hours How many prescriptions are dispensed each year (include all types of Rx)? total Rx/year Which of the following do you have access to (check all that apply): Internet: Pharmacy Home None E-mail: Pharmacy Home None What computer software system do you use? (PDX, QS1, etc.) Who is your pharmacy's primary wholesaler? How did you learn about the NCPA Pharmacy Ownership Workshop? NCPA Fax NCPA E-mail America's Pharmacist Ad Phamacy Times Ad Other

Registration and Payment
Registration:	Member ($595) Non-Member ($770)

Payment Method:	Check (Mailed: ) Credit Card (Visa, Master Card, American Express, or Discover) I can be reached by phone at: If you are paying by credit card, an NCPA staff member will call you to receive your payment information. Please be sure you have provided us with a correct phone number.

Registration Cancellation Policy
Cancellation 14 days prior to the Pharmacy Ownership Workshop is subject to a $50 cancellation fee. No refunds are available after October 20, 2006
* I have read and understand all cancellation policies.

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