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									                                   Distinguished Service Award
                                         Nomination Form
The individual who is selected to receive CSHP's Distinguished Service Award is a member
who has made exceptional and sustained contributions to the Society at the regional and
state levels. In addition, the individual selected:
 Has at least 5 years of extraordinary volunteer service at the state or regional levels of
    CSHP (not necessarily continuous)
 Has been involved in volunteer activities in which the candidate has been involved have
    been critical in helping CSHP achieve its mission
 Has been involved in volunteer activities which have resulted in unusually successful
    and/or high quality CSHP programs, projects, or services for its members
 Is not currently be a member of the Board of Directors, an elected officer or a paid
    employee of CSHP.

Candidate's Name

Institution/Employer:

Address:

City:                                                                  State:   Zip:

Business telephone: (                )                       E-mail:

Pager Number: (              )


Nominator's Name ___________________________________________________

Institution/Employer:

Address:

City:                                                                  State:   Zip:

Business telephone: (                )                       E-mail:

Pager Number: (              )




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Please list the candidate’s CSHP volunteer activities (use a separate sheet if necessary):

      Year                            Description of Activity             Regional
                                                                        Chapter/State




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Explain why you think the candidate’s volunteer efforts have been particularly exceptional to
the Society (use a separate sheet if necessary):




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Nominations for the Distinguished Service Award must be accompanied by 5
letters of recommendation (addressing the criteria) from CSHP members in
good standing who support this nomination. (Letters of recommendation shall
not be submitted by the current chair of the POY/DSA selection committee or by
CSHP’s Executive Vice President).

Please provide the names and addresses of at least five CSHP members who will
be writing letters of recommendation on the nominee’s behalf.

Recommender's Name:

Institution/Employer:

Address:

City:                                                                  State:   Zip:

Business telephone: (                )                       E-mail:

Pager Number: (              )


Recommender's Name:

Institution/Employer:

Address:

City:                                                                  State:   Zip:

Business telephone: (                )                       E-mail:

Pager Number: (              )


Recommender's Name:

Institution/Employer:

Address:

City:                                                                  State:   Zip:

Business telephone: (                )                       E-mail:

Pager Number: (              )




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Recommender's Name:

Institution/Employer:

Address:

City:                                                                  State:   Zip:

Business telephone: (                )                       E-mail:

Pager Number: (              )


Recommender's Name:

Institution/Employer:

Address:

City:                                                                  State:   Zip:

Business telephone: (                )                       E-mail:

Pager Number: (              )


Send the Nomination Form (form must be filled out completely, CV’s are not
forwarded to the selection committee) with a copy of the Candidate’s Curriculum
Vitae and the 5 letters of recommendation to:

                                    Distinguished Service Award
                       c/o California Society of Health-System Pharmacists
                                      1314 H Street, Suite 200
                                   Sacramento, CA 95814-1930


                             Deadline to Submit an Application for the
                             Distinguished Service Award is March 1st.




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