FLSHP Recognition Program - Recommendation Form

TO THE CANDIDATE

Please type your name in the space provided and give this form to a colleague *(i.e., practitioner, administrator or academician) familiar with your contributions to pharmacy practice in acute and ambulatory care settings who can attest to your achievement of the Fellow criteria. This recommendation can be submitted as part of your FASHP application or e-mailed directly to the Office of Member Relations by the person completing it. *Please note, current pharmacy students, current LSHP staff, current LSHP Board members, and current members of the FLSHP Recognition Committee are not eligible to submit recommendations.

Question Title

* 1. Candidate Name

Question Title

* 2. Recommender Name

Question Title

* 3. Title

Question Title

* 4. Affiliation

Question Title

* 5. Street Address

Question Title

* 6. City

Question Title

* 7. State

Question Title

* 8. Zip Code

Question Title

* 9. Telephone

Question Title

* 10. Email

Question Title

* 11. Candidate's professional relationship to you

Question Title

* 12. Length of time of relationship with candidate