Tennessee Pharmacists Association | Board of Pharmacy Nomination

Please familiarize yourself with the Board of Pharmacy Nomination Requirements, then provide the requested information about your nominee below. Shortly after you submit this nomination, your nominee will be sent a one-page application to complete.

You may nominate more than one person by submitting this form again, and you may nominate yourself.

Remember, the deadline for nominations is March 12, 2021.

IMPORTANT INFORMATION REGARDING PHARMACISTS' ELIGIBILITY:
Per Tennessee Code Annotated § 63-10-302
(a) The governor shall appoint the members of the board and shall make appointments so that the pharmacist members of the board shall be graduates of a recognized school or college of pharmacy. In making appointments to the board, the governor shall strive to ensure that at least one (1) person serving on the board is sixty (60) years of age or older and that one (1) person serving on the board is a member of a racial minority.
(b), "No pharmacist shall be eligible for appointment to the board unless such person has been a pharmacist under this or some other law of this state for a period of at least five (5) years, and during the terms of such person’s incumbency shall be actively engaged in the practice of pharmacy."

* = Required Field

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BOARD OF PHARMACY POSITION*

Are you nominating this person to serve on the Board of Pharmacy as a Pharmacist Member or Consumer Member?

Pharmacist Member
Consumer Member

NOMINEE INFORMATION:

NAME*

First Last

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TITLE

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TENNESSEE PHARMACIST LICENSE NUMBER

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HOME ADDRESS

Street Address City State ZIP Code

EMPLOYER

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WORK ADDRESS

Street Address City State ZIP Code

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HOME PHONE

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WORK PHONE

CELL PHONE

EMAIL*

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PHARMACY AFFILIATIONS

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COLLEGE OF PHARMACY

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GRADUATION YEAR

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HIGHEST DEGREE

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YEAR LICENSED

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QUALIFYING EXPERIENCE

QUALIFYING EXPERIENCE:

Please complete the following four fields with regard to the nominee's qualifying experience.

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OCCUPATION

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EDUCATION

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EMPLOYMENT

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OTHER ACTIVITIES

NOMINATOR INFORMATION if different from nominee:

YOUR NAME

First Last

YOUR EMAIL ADDRESS