Select your Desired Role
I am applying for the following vacant seat on the GPhA Board of Directors
At-Large (one 3-year term) or At-Large (one 1-year term)
AEP - Academy of Employee Pharmacists (three-year term)
Contact Information
Name
First Name
Last Name
E-mail
Best Contact Phone Number
-
Area Code
Phone Number
Year Licensed
*
Degree and Designations
Current Pharmacy Practice Setting
Community Retail - Chain
Community Retail - Independent
Health System/Ambulatory Clinic
Long-Term Care/Consulting
Academia
Other
Employer or Pharmacy Name
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Education
Please include college(s), advanced degrees and/or specialized training.
Name and Location of College
Dates (from-to)
Major
Degree Earned
Name and Location of College
Dates (from-to)
Major
Degree Earned
Name and Location of School
Dates (from-to)
Major
Degree Earned
Awards and Honors
Extracurricular Activities
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Work Experience
Employer or Pharmacy Name
Title
Start Date
Briefly describe your responsibilities in your job:
List previous work experience in
reverse
chronological order:
Employer or Pharmacy Name
Title
Dates (from-to)
Employer or Pharmacy Name
Title
Dates (from-to)
Employer or Pharmacy Name
Title
Dates (from-to)
What do you consider your highest career achievement to date?
Please list any business or professional affiliations including any GPhA involvement. Be sure to note positions held and/or specific assignments and periods of affiliation. (Please do not include civic organizations public office, or political activities.)
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Community Involvement
Please outline any community, civic, religious, political, government, social, athletic, or other activities including organization name, assignment or position, and responsibilities
What do you consider your most important accomplishment in one of the above organizations and why?
General Questions
What experience have you had with GPhA?
Have you served on a not-for-profit board before? If so, what was your experience?
What do you think are the characteristics of a great board member?
Board members bring experience, wisdom, strategic thinking, and ideally a network of connections in Georgia Pharmacy. Tell us about yours.
Have you ever received a disciplinary or fine from the Georgia Board of Pharmacy? Yes or No? If yes, please explain why.
Your Availability to Serve
Could you regularly attend bi-monthly (6x a year) board meetings?
Yes
No
As a board member, would you commit to invest in PharmPAC at a dollar level with which you are comfortable?
Yes
No
As a board member, would you commit to contribute to the Georgia Pharmacy Foundation at a dollar level with which you are comfortable?
Yes
No
As a board member, would you participate in recruiting new members to the Georgia Pharmacy Association?
Yes
No
As a board member, would you use your influence to assist the CEO in recruiting corporate partners (chains, wholesalers, vendors, etc.) to engage in and support GPhA?
Yes
No
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Attachments
You MUST attach a photo with your application. Letters of recommendation are optional.
Photo
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Letter of Recommendation 1
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Letter of Recommendation 2
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Letter or Recommendation 3
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AFFIRMATIONS
Time requirements
*
By checking this box, I understand the role of the GPhA Board of Directors, and if I am elected, I will devote the time and resources required by this position.
In good standing
*
By checking this box, I attest that I am in good standing with the Georgia Board of Pharmacy and the Georgia Office of the Inspector General.
Signature
*
By checking this box, I attest that the information contained in this application is correct, and that I am the person named in this application. This serves as my signature.
Email
example@example.com
Email
example@example.com
SUBMIT: Click this button ONLY when you are sure you have completed the entire application. ONCE YOU CLICK HERE, the application is final and may not be amended.
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