Pharmacist of the Year Nomination Form

The IPA Pharmacist of the Year is an individual who has made significant, influential, and sustained contributions to pharmacy practice in California and who is responsible for having a positive impact onpatient care. The recipient of this award is selected for their professional excellence, exemplary service,and dedication to advancing the profession and public health. The award will be granted every oddnumbered year to a qualified candidate.

Nominations can be for fellow IPA members or self-nominations.
Please complete this form for whomever you are nominating.

Are you nominating yourself or fellow IPA member?*

Self-nominationNominating Fellow IPA Member

Is the nominee an ACTIVE IPA Member in good standing?*

YesNo

Nominator Name*

First NameLast Name

Nominator Email*

example@example.com

Nominator Phone*

Please enter a valid phone number.

Nominee Name*

First NameLast Name

Nominee Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Nominee Email*

example@example.com

Nominee Phone Number*

Please enter a valid phone number.

Nomination Letter*

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Any other supporting documents (i.e. support letter, awards/recognitions, CV)

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Optional

*

I certify that the above facts are true to the best of my knowledge and belief.