Relief Student Pharmacist Sign Up Question Title * 1. Please enter your contact information to be posted on a members only website. First and Last Name City State -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming Email Address Primary Phone Number Question Title * 2. I would be comfortable as a relief student pharmacist in the following settings (select all that apply): Community Pharmacy Practice Health-System Practice Long Term Care Practice Other (please specify) Question Title * 3. I am licensed in good standing with the State of Illinois Yes No Question Title * 4. By checking the box below, I agree to have my name, city, and phone number publicly listed and shared on a Members Only page of the IPhA website. I will contact the IPhA office if I wish to be removed from this list. Yes No Done
