The OSHP Richard E. Surface Recognition Award

The OSHP Richard E. Surface Recognition Award

To recognize contributions to and sustained support of OSHP from someone not necessarily a pharmacist. This award was created in 1989 as the OSHP Recognition Award and it was renamed in honor of its first recipient, Richard Surface, in 1999.
Nominee Information
Nominee Name*

First NameLast Name
Nominee Phone Number*

Area CodePhone Number
Nominee Email Address
example@example.com
Nominee Current Employer (if applicable)
Employer’s Address (if applicable)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Professional Title (if applicable)
Nominee Education and Training
Institutions attended, location, dates of graduation, type of training or major subjects, degrees, residencies, fellowships, certificates, major seminars attended, additional training.
Nominee Honors and Awards
Name of award, presenter, description, and date/year presented.
Nominee Work Experience
Professional and Related Experience: (institutions or organizations, locations, dates, type of work or position title.)
Nominee Professional Engagement
Institutional and/or Professional Organization committee work, or other related experience and involvement.
Nominee Significant OSHP Contributions
Other Nominee Significant Contributions
Signiﬁcant Contributions to Profession/Institutions
Additional Significant Information
Any additional information you would like the selection committee to be aware of
Nominator Information
Nominator Name(Individual or Institution)*
Nominator Current Employer*
Employer/Institution Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Nominator Phone Number*

Area CodePhone Number
Nominator Email Address
example@example.com
Additional Nominator Name(s) and Information (if applicable)
Attachments
Nominee’s CV (Required)*

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Additional Evidence #1

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Additional Evidence #2

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Additional Evidence #3

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Please note that you will NOT receive an email confirming your submission, but you should see an on-screen confirmation.
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