Tennessee Pharmacists Association | Award Recipient Information Form

CONGRATULATIONS on winning your award! We look forward to recognizing you for this honor. To help us celebrate your achievements, please fill out and submit the following form, along with the requested file uploads.

If you have any questions, please do not hesitate to contact Lisa Hull at the TPA office: lisa@tnpharm.org or 615-256-3023.

* = Required Field

RECIPIENT INFORMATION

NAME AND CREDENTIALS:

Please enter your name and credentials exactly as you wish them to appear on your award, unless you have already provided that information to TPA.

NAME FOR AWARD PRESENTATION:*

Please enter your name exactly as you wish it to be announced during the Awards Ceremony.

NAME FOR PRESS RELEASE:*

TPA will develop a press release about your winning the award. Please enter your name exactly as you wish it to appear in your press release. We will email it to you, so that you can provide it to the media outlets of your choice.

HOME ADDRESS:

MAY SKIP IF PROVIDED IN CV/RESUME

Street Address - Line 1 Street Address - Line 2 City State Zip Code

WORK ADDRESS:

MAY SKIP IF PROVIDED IN CV/RESUME

Street Address - Line 1 Street Address - Line 2 City State Zip Code

MAIN CONTACT PHONE NUMBER:*

What phone number do you prefer we use to contact you?

MAIN CONTACT PHONE TYPE:*

Please indicate if the phone number above is a cell phone, work phone, or home phone.

Cell Phone
Home Phone
Work Phone

MAIN CONTACT EMAIL ADDRESS:*

EDUCATION / DEGREE INFORMATION

PHARMACY SCHOOL/COLLEGE, DEGREE, and GRADUATION YEAR:

MAY SKIP IF PROVIDED IN CV/RESUME

EMPLOYMENT INFORMATION

CURRENT PLACE OF EMPLOYMENT:

MAY SKIP IF PROVIDED IN CV/RESUME

YOUR TITLE:

MAY SKIP IF PROVIDED IN CV/RESUME

YEAR YOU STARTED:

MAY SKIP IF PROVIDED IN CV/RESUME

LOCATION:

MAY SKIP IF PROVIDED IN CV/RESUME

PRIMARY PRACTICE TYPE:*

ADDITIONAL INFORMATION

RECENT WORK HISTORY:

MAY SKIP IF PROVIDED IN CV/RESUME

PLEASE INCLUDE YEARS.

PROFESSIONAL INVOLVEMENT IN TPA AND/OR TPA SOCIETIES:*

Include offices held, honors, awards... anything else! PLEASE INCLUDE YEARS.

OTHER ASSOCIATION OR PROFESSIONAL INVOLVEMENT:*

Include offices held, honors, awards... anything else! PLEASE INCLUDE YEARS.

CIVIC AND COMMUNITY INVOLVEMENT, FAMILY, ETC.:*

PLEASE INCLUDE YEARS if applicable.

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AWARDS CEREMONY

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WILL YOU BE ATTENDING THE AWARDS CEREMONY (FRIDAY EVENING, JUNE 21) DURING THE 2019 TPA SUMMER MEETING?

Yes
No

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NAMES OF YOUR GUESTS:

Please list the names of people who will be attending the Awards Ceremony with you as your guests. Four complimentary guest tickets will be provided to you for the day of the ceremony. If you will have more than four guests, additional tickets may be purchased. Once meeting registration is open, you will be sent a link where you or your guests may purchase additional tickets.

FILE UPLOADS

If you have any difficulty uploading files, please email them to lisa@tnpharm.org.

PHOTO (HEADSHOT):

SKIP IF ALREADY PROVIDED TO TPA

Please upload a high-resolution headshot of yourself.

Drop files here or

Max. file size: 256 MB.

PHOTOS FOR AWARDS PRESENTATION:

Please upload photos you would like to appear on-screen during the awards presentation. These can be a mix of you at work, as well as events, family, honors, achievements, etc. Approximately 10 photos are recommended.

Drop files here or

Max. file size: 256 MB.

CV:

If not providing a CV or resume, all fields above must be completed.

Drop files here or

Max. file size: 256 MB.