Fellow of The Ohio Society of Heath-System Pharmacy (FOhSHP) Application
Please complete the form and attach your CV and support letters to proceed.
Nominee’s Full Name
*
First Name
Last Name
Nominee’s Email Address
*
example@example.com
Nominee’s Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Current Employer
*
Current Job Title
*
Ohio Pharmacist License Number
*
Is the nominee's Ohio pharmacist license currently active and in good standing? (Retired pharmacists are exempt)
*
Yes, active and in good standing
Retired pharmacist (exempt)
No
Years of Active OSHP Membership as a Full Member (must be more than 10 years as a licensed pharmacist; student membership does not count)
*
Are you Currently a Member of OSHP?
Yes
No
Year in Which the Nominee Became a Full Member of OSHP
*
Baseline Professional Information
Year of Completion of Highest Professional Pharmacy Degree
*
Degree Earned (e.g., PharmD, BSPharm)
*
Year of Completion of PGY1 Residency (if applicable)
Year of Completion of PGY2 Residency (if applicable)
Year of Completion of Clinical Fellowship (if applicable)
Current Employer (Baseline Info)
*
Current Job Title (Baseline Info)
*
Upload Nominee’s Most Recent CV or Resume
*
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Name of Individual Providing Letter of Support #1
*
Name of Individual Providing Letter of Support #2
*
Name of Individual Providing Letter of Support #3
*
Upload Letter of Support #1 (Optional: author may submit in this section at this link https://form.jotform.com/ohioshp/letter-of-recommendation-submission)
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Upload Letter of Support #2 (Optional: author may submit in this section at this link https://form.jotform.com/ohioshp/letter-of-recommendation-submission)
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Upload Letter of Support #3 (Optional: author may submit in this section at this link https://form.jotform.com/ohioshp/letter-of-recommendation-submission)
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Submit Nomination
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