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ACT Pharmacy Collaborative Commitment Form

AACP Resource

This form should be completed by the Primary ACT Champion for your institution. Please be sure to attach the completed Dean’s Statement of Commitment as a PDF and include information for all ACT Champions at your institution. 

Indicates required field
Institution Name
Primary ACT Champion Information
Contributions

Choose the ACT Champion's contribution(s) to advancing community pharmacy practice based on their role(s) at the institution. Select all that apply.
Upload the preferred logo for your school/college to be used for the ACT Pharmacy Collaborative website. You only need to upload the logo if your college/school is new to the Collaborative or if your logo has been updated since it was last shared. 
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.