Registration is now open!Please complete the form below. registration details School/College/University * Primary Contact Information name * title and position * Phone Number * Cellphone Number Email address * Alternate Contact Information name title and position Phone Number Cellphone Number Email address Regional Competition Dates If you have already scheduled your Regional Competition, please enter the dates below in order to coordinate the shipment of chemicals. Start Date Month MonthOctNovDecJan Day Day12345678910111213141516171819202122232425262728293031 Year Year20182019 End Date (if held over multiple days) Month MonthOctNovDecJan Day Day12345678910111213141516171819202122232425262728293031 Year Year20182019 Alternate Dates If you have not confirmed the dates for your Regional Competition, please provide some approximate dates below (e.g., mid-October, November 20-24, etc.) Number of teams participating * Each team must include 3 students (there is a maximum of 12 teams). Shipping Information Required for shipment of chemicals. Contact Name * Receiving Address * City * State * Zip Code * Stay in Touch! I hereby give consent to receive electronic communications from LP3 Network and its affiliates for marketing purposes. Authorized Signature submit * I hereby submit this Registration Form for participation in the 2018-2019 Student Pharmacist Compounding Competition. Name * Email address If different from the Primary Contact Information above. submission Please review the information above and click the "SUBMIT" button below. Thank you! Leave this field blank
