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Michigan Pharmacists Association Nomination Form
Nominating For:
*
MPA Executive Board
Consultant and Specialty Pharmacists of Michigan (CSPM) Board of Directors
Michigan Society of Community Pharmacists (MSCP)
Michigan Society of Health-System Pharmacists (MSHP)
Michigan Society of Pharmacy Technicians (MSPT)
Executive Board Position
*
MSCP Representative
MSHP Representative
MSPT At-Large
President-Elect
MSHP Board Position
*
Director
President-Elect
*Please note that MSHP nominations will not be accepted after May 15.
*Please note that Section Board nominations will not be accepted after June 1.
Nominee Information
Name
*
Pronouns:
*
She/Her/Hers
He/Him/His
They/Them/Theirs
Ze/Zir/Zirs
Other
If other, please list what pronouns are used:
*
Practice Site
*
Email Address
*
Cell Phone Number
*
Business Phone Number
Year of pharmacy school graduation
College
Involvement in local or state activities and organizations
*
Pharmacy association memberships
Resume or CV:
Nominator's Information
Name
*
Phone Number
*
Email Address
*
Is the nominee aware of your nomination?
*
Yes
No
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