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Nomination Form for IPSF Pharmacy Education (PE) Ambassadors

1.

2.

Personal Information :
a. Name

______________________________________________________

b. Pharmacy School

______________________________________________________

c. Year of Study

______________________________________________________

d. Association

______________________________________________________

e. Country

______________________________________________________

a. E-mail address

______________________________________________________

b. Telephone Number

+ ___

c. Skype ID

______________________________________________________

d. Postal Address

______________________________________________________

Contact Information

(country code)

_______________________________________

______________________________________________________
______________________________________________________

Please consult IPSF Contact Person in your country and submit the completed nomination
form to the Chairperson of Pharmacy Education (education@ipsf.org) and Pharmacy
Education Research Coordinator (research@ipsf.org) no later than Friday, 28th February
2014.

IPSF Secretariat: Andries Bickerweg 5, P.O. Box 84200, 2508 AE The Hague, The Netherlands.
Tel: +31-70-302 19 92 - Fax: +31-70-302 19 99 - Email: ipsf@ipsf.org - Website: www.ipsf.org
Registered under Dutch Law: 40413709