Tennessee Pharmacists Association | TPA Awards Committee Application

YOUR NAME:*
First Last
YOUR EMAIL ADDRESS:*
YOUR PHONE NUMBER:*
YOUR HOME ADDRESS:*
Address Line 1 Address Line 2 City State Zip
YOUR EMPLOYER:*
Please enter N/A if you are not currently employed.
YOUR EMPLOYER'S ADDRESS:
Address Line 1 Address Line 2 City State Zip
YOUR SOCIETY MEMBERSHIP(S):*
Select which society you belong to.
- Tennessee Compounding Pharmacists Society (TCPS)
- Tennessee Society of Chain Pharmacists (TSCP)
- Tennessee Society of Health-System Pharmacists (TSHP)
- Tennessee Society of Independent Pharmacists (TSIP)
- Tennessee Society of Long-Term Care Pharmacists (TSLTCP)
- Tennessee Society of Pharmacists (TSP)
- Tennessee Society of Pharmacy Technicians (TSPT)
- Tennessee Society of Student Pharmacists (TSSP)
PRIOR TPA LEADERSHIP/COMMITTEE SERVICE:*
Select all that apply
- TPA/TSHP Committee
- TPA Delegate
- TPA Society Leader
- TPA Board Member
- Other
- No TPA Leadership or Committee Service
If you checked "Other", please list prior TPA service not included in the list provided above.
AVAILABLE SERVICE AREAS
Please select the areas of service you are interested in.
TPA Committees*
I am interested in serving on the following committee(s). (check all that apply)
- TPA Awards Committee
- TPA Continuing Education Committee
- TPA Legislative and Regulatory Policy Committee
- TPA Nominations Committee
- TPA Resolutions Committee
- TPA ad hoc Collaborative Pharmacy Practice Committee
- TPA ad hoc Membership Engagement Committee
- TPA ad hoc Strategic Planning Committee
- TSHP Awards Committee
- TSHP Clinical Managers/Coordinators Committee
- TSHP Membership Engagement Committee
- TSHP Nominations Committee
- TSHP Programming and Education Committee
- TSHP Residency Committee
- TSHP Strategic Planning Committee
- TSHP ad hoc Directors of Pharmacy Committee
- I am not interested in serving on a committee
House of Delegates*
Please select the position you are interested in.
- Delegate Only
- Alternate Delegate Only
- Either Delegate or Alternate
- I am not interested in serving in the TPA House of Delegates
Society Leadership | Elect Postions*
Please select which area(s) you are interested in serving in.
- Society Chair/President-Elect
- Society Secretary/Treasurer Elect
- I am not interested a society leadership position.
Non-TPA Leadership Postitions*
Please select all that apply.
- Tennessee State Board of Pharmacy
- Other Regulatory Boards
- TennCare Advisory Committee
- Elected Official (city council, state legislature, etc)
- I am not interested in non-TPA leadership positions
If you answered "Other Regulatory Boards" above, please specify the agency of interest:
Example: Serving on another health professional board as the Public Member.
Please list any other non-TPA leadership roles you are interested that may not be listed above.
Which best describes you?*
- Pharmacist
- Pharmacy Resident/Fellow
- Pharmacy Technician
- Student Pharmacist
Are you a past TPA President?*
- Yes
- No
ADDITIONAL COMMENTS:

Please use the space below to provide additional comments, if desired.
Upload CV/Resume*
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TPA Awards Committee Application

AVAILABLE SERVICE AREAS