PTCB Advocate Employer Program Application and Agreement

* Please note: If you represent a single location that is part of a larger entity, please forward this form and program information to your company’s headquarters.


** This application may only be completed by an authorized director or other management-level representative of the identified applicant company. Otherwise, please forward this form and program information to your employer.

Primary Contact Information

Company

Prefix [optional]

First Name

Middle Name [optional]

Last Name

Suffix [optional]

Designation [optional]

Title [optional]

Country [optional]

Street Address 1

Street Address 2 [optional]

City

State/Province

Zip/Postal Code

Telephone

Fax [optional]

Email Address

Company Website Address [optional]

Alternate Contact Information

Prefix [optional]

First Name [optional]

Middle Name [optional]

Last Name [optional]

Suffix [optional]

Email Address [optional]

Title [optional]

Company Information

Which of the following best describes your primary work environment? [optional]










How many total employees does your company employ? [optional]

Of your total employees, how many are pharmacy technicians? [optional]

Where does your company employ pharmacy technicians? (List all states that apply). [optional]


Or select: [optional]




Additional Comments [optional]

Does your company require a pharmacy technician to be certified before hiring? [optional]



Have you promoted PTCB to your employees in the last 6 months? [optional]


How did you hear about the PTCB Employer Partnership Program? (choose all that apply) [optional]







If other please specify [optional]

Applicant Representative's Name

Company

Date (enter in mm/dd/yyyy format)