APhA-ASP House of Delegates
MRM Chapter Delegate Credentials Form

Please complete the following form to serve as your Chapter's Delegate. As your chapter representative, you will receive your chapter's ballot and cast the vote for the region's proposed resolution statements, regional officer candidates, and innovative programming poster.

APhA-ASP Chapter Delegates will be the only chapter members to receive the ballot that allows for voting and amendments. Chapter delegate registration must be completed by October 10 at 11:59 pm PT.

As the APhA-ASP Chapter Delegate, you should participate in your region's policy discussion and review the chapter delegate training materials. The time and date for the chapter delegate and policy sessions can be found on the MRM website.

All APhA-ASP members (and non-members) are encouraged to participate in the APhA-ASP Policy Proposal Forum on Sunday of the MRM to voice their opinions on the proposed resolutions and new business items.

If you have any questions or concerns regarding the process, please contact APhA-ASP at APhA-ASP@aphanet.org.

Chapter Delegate Contact Information

Please choose your Region: *

School or College of Pharmacy *

Please note if your school or college of pharmacy has multiple campuses or satellite campuses, only one Chapter Delegate is permitted in the APhA-ASP House of Delegates from each accredited school or college of pharmacy.

Primary Chapter Delegate Information

First Name: *

Last Name: *

Chapter Leadership Position: *

APhA Member ID#: *

Email Address: *

Phone Number: *

Alternate Chapter Delegate Information

First Name: *

Last Name: *

Chapter Leadership Position: *

APhA ID#: *

Email Address: *

Phone Number: *

Confirmation

Confirmation: *

I attest that the above student pharmacists have been selected by our APhA-ASP Chapter and/or our school or college of pharmacy to represent our APhA-ASP Chapter as a Delegate. They have the support of the faculty and administration as well.

Name *

APhA-ASP Chapter Position *

*

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APhA-ASP House of Delegates MRM Chapter Delegate Credentials Form

Chapter Delegate Contact Information

Primary Chapter Delegate Information

Alternate Chapter Delegate Information

Confirmation

APhA-ASP House of Delegates
MRM Chapter Delegate Credentials Form