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* Mandatory fields
*First & Middle Name
*Prefered Name
*Last Name
*Greeting
Credentials
e.g., PharmD, BCSP, RPh, PhT, CPhT, RN, FASHP or advanced degrees such as PhD, MBA, MHA
*Organization
INCLUDE THE INFORMATION THAT CORRELATES WITH YOUR MEMBERSHIP LEVEL
* PHARMACIST: Employer/Company/Hospital Name
* STUDENT: PharmD Program & est Graduation Date (MM/YY)
* PGY1/PGY2: Residency Program & est start dates (PGY1 MM/YY & PGY2 MM/YY)
*Position
e.g., Job Title, Student OR PharmD candidate
Pharma
YES = All individuals who work for pharmaceutical companies
*Primary Phone with Area Code
cell/other
*Texts
May we send you occasional text messages?
*Primary Email
Secondary Email
*Home Address
*Home City
*Home State
*Home Zip
Congress Dist
CSHP will add this once we know your local/CT home address.
Date Joined
Enter your date of application
Referred Member
Provide the full name of the person who referred you to CSHP.
Work Address
Work City
Work State
Work Zip
Work Area code
Work Phone Number
Director
Clear selection
Select all that are applicable
Education
STUDENT MEMBERS MUST PROVIDE AN ANTICIPATED GRADUTION DATE. All others, provide your degrees, where you earned your degrees and when(optional)you earned your degrees.
Specialty
Describe your particular area of practice/medical specialty; for associates, what medical areas do your products address
Pharm license number
Provide your CT pharm license number
NABP #, month/day of birth
Provide NABP # AND Month/Day of birth to receive CE credit
ASHP membership
Volunteer Interest
Check Get Involved for options. Type in mentoring newer professionals; work on a specific committee, task force or initiative; assist with CTW or other conference; nominations; etc.
Ambassador
Spread the word about CSHP and our activities at your facility. Encourage people to join CSHP.
PTCB
Other Memberships
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About CSHP

Since 1948, the Connecticut Society of Health-System Pharmacists has represented the professional interests and provided professional development for CT pharmacists, educators and pharmacists in training.

Contacts

c/o Impact Association Management 

1502 W Broadway, Suite 102

Madison, WI 53713

Phone: 203-489-9861


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