| First Name: |
|
| Last
Name: |
|
| Address |
|
| Tel N° |
|
| Fax N° |
|
| E-mail
Address |
|
|
| Field
of pharmacy practice (very brief description of work and
focus of interest): |
|
|
| 1.
Participation in areas described in the project: |
|
| 1.1
Supply of books, computers, literature services etc |
Describe needs:
|
|
Describe potential offers:
|
|
| 1.2
Fellowships, faculty exchange etc |
Describe needs:
|
|
Describe possible
offers/cooperation:
|
|
| 1.3.
Twinning arrangements |
I/institution
etc am/is interested in establishing a twinning
relationship (for e.g. exchange of information, visits,
support etc.) with an institution or an individual as
follows:
|
|
national pharmacists association |
faculty of
pharmacy |
|
hospital pharmacy |
drug information centre |
|
individual
pharmacist |
|
| Other
(please describe): |
|
|
2. Information
on other ongoing schemes falling within the scope of
Pharmabridge
(e.g. Pharmaid as operated by the
Commonwealth Pharmaceutical Association,
or a fellowship scheme for pharmacists from
developing countries) |
| 2.1 Describe such schemes:
|
|
2.2 Indicate whether you agree that these schemes could be referred to as
additional
information/link under the Pharmabridge project
|
|
|
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3. General Suggestions/Comments
|
| Description: |
|
| 4. In the event that a list of addresses of people participating in
Pharmabridge would be established for inclusion on the Pharmabridge website,
would you agree that your name and contact information would be included in such
a list?
|
|
Yes
|
No
|
|
Signature:
__________________________________________ |
Name of person
signing:
_____________________________________________ |
Please fill in in
legible characters. The preferred way of receiving
completed questionnaires is by e-mail.
|