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ACT Pharmacy Collaborative Commitment Form

This form should be completed by each school/college’s designated ACT Champion. Please be sure to attach the completed Dean’s Statement of Commitment as a PDF.

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Designated ACT Champion Information

First Name

Last Name

College/School of Pharmacy

Academic Title

Email Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Work Phone Number

Cell Phone Number

Please enter your School or College’s relevant Instagram handle, if applicable.

Please enter your School or College’s relevant page name on Facebook, if applicable.

Please enter your School or College’s relevant Twitter handle, if applicable.

Please upload the preferred logo for your school/college to be used for the ACT Pharmacy Collaborative website.

One file only.
100 MB limit.
Allowed types: jpg, png.

Please upload a PDF of the signed Dean’s Statement of Commitment, signifying your school or college’s commitment to participating in the ACT Pharmacy Collaborative.

One file only.
100 MB limit.
Allowed types: pdf.

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ACT Pharmacy Collaborative Commitment Form

Designated ACT Champion Information