IPA Interests Survey

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1.	First Name:*

2.	Last Name:*

3.	I am a:
	Pharmacist
	Pharmacy Technician
	Student Pharmacist
	Other

4.	List Credentials

5.	Email:*

6.	Practice Setting:* Please choose the practice setting that best aligns with your current role.
	Independent Pharmacy
	Chain / Supermarket / Mass-merchant Pharmacy
	Hospital / Health-system Pharmacy
	Ambulatory Care / Clinic-based Practice
	Academia
	Long-term Care Pharmacy
	Pharmaceutical Industry
	Federal Pharmacy
	Managed Care Pharmacy
	Other, please specify

7.	Title:

Check as many opportunities that you are interested to be considered for.

8.	Annual Committees - Limited positions available, 1 year terms: Read more on these positions at https://www.iarx.org/committeestaskforces.
	Policy Committee on Professional Affairs
	Policy Committee on Public Affairs
	Education Advisory Committee
	Legislative Advisory Committee
	Advisory Committee on Practice Transformation
	Advisory Committee on Innovation and Growth
	Advisory Committee on Amplified Voice
	Student Pharmacist Advisory Committee

9.	Unlimited Positions Available
	Journal of the Iowa Pharmacy Association (JIPA) Peer-Reviewer
	Presenter on an area of expertise or research project

10.	Appointed or Elected Position (Limited Availability) Read more on these positions at https://www.iarx.org/leadershipopportunities.
	IPA Board of Trustees
	Delegate to IPA House of Delegates
	Ad-hoc Task Force or Working Group

11.	Assistance Available from IPA staff
	National pharmacy leadership and volunteer positions (i.e. ASHP, APhA, ASCP, ACCP, NCPA)

12.	IPA Board of Trustees Officer Positions
	President-elect (3 year term: President-elect --> President --> Chair of Board) Elected by the IPA Membership
	Vice-Speaker of the House of Delegates (2 year term: Vice Speaker --> Speaker of the House) Elected by the IPA House of Delegates
	Treasurer (3-year term; up to 2 consecutive terms can be served) Appointed by the IPA Nominations Committee

13.	Civic Engagement
	Candidate for the Iowa Board of Pharmacy
	Candidate for other Governor-appointed state regulatory boards or councils
	Interest in running for an elected office
	Interest in other local or statewide civic engagement opportunities to represent the profession of pharmacy/IPA

14.	Political affiliation is often a criterion in determining Governor-appointed state regulatory boards or councils. If interested in serving on a regulatory board, please list your political affiliation.