Please print the point system/rubric on the information page to assist with assigning points. If you participated in the activity, indicate the MAXIMUM number of points next to the activity. If you did not participate in an activity, leave blank.

Disclaimer: It is important to review the points document in its entirety and be prepared to enter all information once you start the application. If you do not complete the application may not save.

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* 1. Nominee

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* 2. Nominated by
(Self-nominations are accepted)

Please enter the nominee's information below.

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* 3. Email Address

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* 4. Phone

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* 5. Place of Employment

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* 6. Job Title

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* 7. FL License Number
(Must have an active Florida pharmacist license in good standing. Retired pharmacists are exempt.)

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* 8. Years of practice since initial licensure
(Must have at least 10 years of pharmacy practice experience at the time of application, 7 of these must be health- system pharmacy practice experience in an institutional or ambulatory care setting)

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* 9. FSHP Member Type (at time of application)

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* 10. Years of FSHP pharmacist membership
(Must have at least 5 years of pharmacist membership status at the time of application, does not need to be consecutive years)

*500 points are required to be considered for FSHP Fellowship Program, with 160 points coming from Section A: Sustained contribution to FSHP

Exclusions: Industry-sponsored presentations will not count for fellowship points. Encore poster and podium presentations will count only one time regardless of the number of times presented. Current members of the FSHP Board of Directors and/or FSHP Foundation Board of Directorsare not eligible to apply during their terms in office.

Conflict of Interest Statement: Anyone working on the Fellowship charge or evaluation of candidates is excluded from applying for Fellowship during that year of service (Professional Affairs Council member, Foundation member, etc.)

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