Award Nomination Form

In order to nominate an awardee (self-nomination is acceptable), please submit the form below.

CPA AWARDS NOMINATION FORM

Your Name *

First

Last

Your Email *

I verify that I am a CPA member in good standing and therefore eligible to nominate for any CPA award. *

Both the nominator and the nominee must be members in good standing of the Connecticut Pharmacists Association. Please verify that you (the nominator) are a CPA member in good standing and therefore eligible to nominate yourself or others for these awards. We will verify your membership status as well as that of the nominee.

Select the Award

Please choose which award you are nominating for (one only). If you wish to nominate for more than one award, each nomination must be submitted separately.

Dropdown *

Name of Nominee *

First

Last

Please insert the name of the person you are nominating (may be yourself).

Nominee Email

Letter of Support

In 500 words or less, please provide a letter of support for this nominee--tell us (with as much detail as possible) why this nominee deserves this award. Alternatively, you may submit the Letter of Support as a separate document and upload it below.

Letter of Support

File Upload

You may upload your letter of support here.

Name