Pharmacist of the Year Nomination Form

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*

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

Optional
Cancelof
I certify that the above facts are true to the best of my knowledge and belief.
Should be Empty: