AKPhA Fellowship Award Application Form

Award Application - Fellow of AKPhA (Deadline to Submit 12/1/23)

Pharmacists who have been members of AKPhA for over 10 years are encouraged to apply for our Fellowship designation. This award recognizes the recipient's achievements and dedication to the practice of pharmacy and the community, and to mentoring future pharmacy leaders. Fellows will be honored at Convention as mentors to new members, first-time attendees, and our New Practitioners/Young Leaders Committee. This designation is for life as long as the individual is an active member of AKPhA. Must be a current member of AKPhA and a member for over 10 years, and NOT on the awards committee.

Appliant's Name*
First Last
Applicant's Main Phone
Applicant's Mailing Address*
Street Address City State ZIP Code
Applicant's Email*
Applicant's Practice Location
1. Applicant's CV*
Drop files here or

Max. file size: 256 MB.
2. Board Certifications
3. Letters of Recommendation
Letter of Recommendation One*
Max. file size: 256 MB.
Letter of Recommendation Two*
Max. file size: 256 MB.
Letter of Recommendation Three*
Max. file size: 256 MB.
4. Number of Years in Pharmacy Practice (10 years minimum)*
5. Membership with the Association
a. How many years have you been a member of AKPhA? (10 Years Minimum)*
b. Roles Within the Association (Select All that Apply)
- Committee Member
- Committee Chair
- Board Member
- President
c. Awards Within the Association
6. Contribution to the total body of knowledge in pharmacy (One or more of the following)
a. Publication in Peer Reviewed Journal (Please provide example)
b. Publication in Textbook (Please provide example)
c. Presentations at Professional Meetings (Please provide example)
d. Production/Publication of Educational Tools/Aids (Please provide example)
7. Involvement in and Commitment to Education of Others (One or more of the following)
a. Presentations to Health Care Providers
b. Precepting Residents
c. Precepting Students
d. Mentoring
8. Active Involvement and Leadership in Professional Activities (One or more of the following)
a. Served as elected officer of a national, state, regional, or local pharmacy association (please provide example)
b. Served as a member of a commission, committee, task force, or ad hoc group established by a national, state, regional, or local pharmacy association (please provide example)
c. Reviewer of Presentations/Posters (please provide example)
9. Academic and/or Research Grants
10. Public Service--Charitable organization, PTA Board Member, Elected Government Official, Sports Coach, Youth Organization Leader, Church Leader, etc. (Please provide example)
11. NOT a current Awards Committee Member*

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Award Application - Fellow of AKPhA (Deadline to Submit 12/1/23)

3. Letters of Recommendation

5. Membership with the Association

6. Contribution to the total body of knowledge in pharmacy (One or more of the following)

7. Involvement in and Commitment to Education of Others (One or more of the following)

8. Active Involvement and Leadership in Professional Activities (One or more of the following)

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