Pharmacist Specialists At Large
Interest Form

First name*

Last name*

Email*

Primary Practice Setting (Current or most recent)*

Years of post-licensure acute care expereince*

0-2 years

3-5 years

5-8 years

> 8 years

Post-Graduate Training*

PGY1

PGY2

Please list residency training sites:*

Board Certifications (please list):*

Active Pharmacist Licenses (please list Active states):*

Additional applicable qualifications:*

In one or two sentences, describe the type of clinical decisions you are most often trusted to make independently.*

Briefly describe a high-acuity clinical scenario you manage comfortably without supervision. Do not include PHI - general description only.*

Have you previously provided physician-facing consultation or on-call clinical support?*

Yes

What draws you to consultative, advisory clinical work rather than traditional staffing roles?*

Estimated future availability (select all that apply):*

Days

Evenings

Nights

Weekends

Holidays

PRN

Please confirm the following:*

I understand APS provides educational pharmacotherapy consultation only and does not deliver direct patient care

I am comfortable operating in a consultative, independent clinical role

I understand this form does not guarantee engagement or future work

Anything else you believe is important for APS leadership to know?

Kingman, Arizona 86401

bottom of page