Continuing Education Credit Request Form
Midwest Pharmacy Residents Conference
Please print the following information:
Name: _____________________________________________________________________________
Last four digits of Social Security# (Required)____________Date of Birth(MM/DD)________________
The CPE Monitor (NABP e-Profile #):___________________________________________(6-10 Digits)
** You may obtain your CPE Monitor (NABP e-Profile) Number by calling 847-391-4406 or by visiting
the following website:
Street Address: _____________________________________________________________________
City: ____________________________________ State: _____________ ZIP:___________________
Place of Employment:_________________________________________________________________
Daytime Phone#_____________________________ Daytime Fax#____________________________
The Midwest Pharmacy Residents Conference is sponsored by the Nebraska
Council for Continuing Pharmacy Education (NCCPE). NCCPE is accredited by
the American Council for Pharmacy Education (ACPE) as a provider of
continuing pharmacy education (CPE). The ACPE Universal Activity Numbers (UAN)
for this year’s conference can be found on the conference schedule next to each CPE
session. Participants will be awarded one (1) contact hour of continuing pharmacy
education or 0.10 CEUs per hour of completion.
In order to receive CPE credit, participants must attend the CPE session in its entirety
as no partial credit will be awarded. Participants requesting CPE credit will also be
required to complete all self-duplicating speaker evaluation forms for each CPE session
attended and within 14 days following the conference, complete an online survey for all
speakers within each CPE session attended during the conference. An email will be sent
to those requesting CPE following the conference with instructions on how to proceed.
Participants requesting CPE credits will be required to provide their NABP e-Profile ID
number (6 – 10 digit number) and date of birth (month and day only – MM/DD). If a
participant does not have an NABP number, he or she will need to request a number by
registering online at
CPE activities at The Midwest Pharmacy Residents Conference are Knowledge-based.
Receipt – Please complete form and submit with $15.00

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