TSHP Residency Committee Application

Thank you for your interest in serving on the TSHP Residency Committee! To get started, please complete the form below.

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YOUR NAME:*

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YOUR EMAIL ADDRESS:*

YOUR PHONE NUMBER:*

PHONE NUMBER TYPE:*

The phone number listed above is your...

Cell Phone
Home Phone
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YOUR HOME ADDRESS:*

Address Line 1 Address Line 2 City State ZIP Code

YOUR EMPLOYER:*

Please enter N/A if you are not currently employed.

YOUR POSITION:

Please include your role(s) as PGY1 or PGY2 Residency Program Director and/or Preceptor.

YOUR EMPLOYER'S ADDRESS:

Address Line 1 Address Line 2 City State ZIP Code

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YOUR SOCIETY MEMBERSHIP(S):*

Current TPA members who hold membership in the Tennessee Society of Health-System Pharmacists (TSHP) are eligible to serve on TSHP committees. TSHP members may submit applications to serve on both TPA and TSHP committees. Applicants must be current on their membership when they apply and throughout the committee term, if selected.

Tennessee Society of Health-System Pharmacists (TSHP)
Tennessee Compounding Pharmacists Society (TCPS)
Tennessee Society of Chain Pharmacists (TSCP)
Tennessee Society of Independent Pharmacists (TSIP)
Tennessee Society of Long-Term Care Pharmacists (TSLTCP)
Tennessee Society of Pharmacists (TSP)

ADDITIONAL COMMENTS:

Please use the space below to provide additional comments, if desired.

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