NJPhA Immunizing Pharmacist Network
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First Name:
Last Name:
Email Address:

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Preferred Contact Number


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I currently live in (enter city name):


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I would be comfortable as an immunizing pharmacist in the following settings (select all that apply):
Hospital Practice
Long Term Care Practice
Community Practice
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Please provide your digital signature to attest that you are licensed in good standing in the state of New Jersey and have obtained and maintain your immunization license from the NJ Board of Pharmacy.

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Additional Comments


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