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Subscription form

* Mandatory fields
*First & Middle Name
What is your preferred first name?
*Last name
ex. PharmD, BCSP, RPh, PhT, CPhT, RN, FASHP or advanced degrees such as PhD, MBA, MHA
Employer, or if you are a student, the name of your PharmD Program. STUDENTS MUST INCLUDE AN ANTICIPATED GRADUATION DATE.
Job title or if a student, PharmD candidate (be sure to include an anticipated graduation date)
YES = All individuals who work for pharmaceutical companies
*Phone with area code
primary phone number
May we send you occasional text messages?
Email 2
secondary email address
*Home Address 1
Please provide a personal, local mailing address.
*Home City
*Home State
*Home Zip
We will use this address for mailings
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
W City
W State/country
W Zip
W Area code
W Phone
Clear selection
Select all that are applicable
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.
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.
Spread the word about CSHP and our activities at your facility. Encourage people to join CSHP.

About CSHP



c/o Impact Association Management

5329 Fayette Ave

Madison, WI 53713

Phone: 203-489-9861

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