2015-19 Ohio Board of Pharmacy Vacancy Nomination Form

TO APPLY:
January 2, 2015 is the deadline for submitting nominations to the OPA Board of
OPA Legal & Regulatory Committee. For your convenience, a nomination form follows.
For more information, contact the OPA office at 614.389.3236 or opa@ohiopharmacists.org.
Application For Ohio Board of Pharmacy Vacancy
Applicant Name
(First/Middle/Last)
Address
City/State/Zip
Phone
Email Address
Qualifications and reasons for application
(You may paste a resume of educational, professional and civic experiences into the above box or email it to opa@ohiopharmacists.org.)
Political Party Affiliation
(Note: The Governor's office will review your voting record for the past six years.)
Are you an Ohio Pharmacists Association member?
 
Can you be away from your place of employment at
least 36 days per year?
Are charges pending or have you been convicted of a felony or a misdemeanor other than a minor traffic violation?
 
Have you been the subject of disciplinary action by any state or federal agency?
 
The OPA Legal and Regulatory Committee may contact you for an interview or additional information.
Remarks­
 
Nominated by
(First/Middle/Last)
Date
Email Address
Please submit by January 9, 2014
Or mail to:
Legal and Regulatory Committee
Ohio Pharmacists Association
2674 Federated Blvd.
Columbus, Ohio 43235
   - denotes required fields