ISPE Student Chapter Application

Thank you for your interest in creating an ISPE Student Chapter.

Please thoroughly review and complete this application to be recognized as an active ISPE Student Chapter. If you have questions, you can find information on the ISPE website or by emailing info@pharmacoepi.org. Your application will be reviewed and put before the Executive Committee and/or Board for final approval.

In addition to submitting a completed application, please upload PDFs of the following two letters to this form.

Letter One From the Chapter President and Advisor

Please include the following in your letter of application

Reference the chapter name, the Faculty Advisor's name, and the Chapter President's name.
An introduction to the Faculty Advisor, including an explanation of why this person is capable of serving for your organization and your advisor's involvement with ISPE and pharmacoepidemiology.
A detailed description of the student interest and capacity in forming an ISPE Student Chapter (i.e., Why do the students at your university want to form an ISPE Student Chapter?).
An outline of how often the Student Chapter will meet and the types of pharmacoepidemiologic activities it plans to participate in.

Letter Two From the University

A letter from the University/Educational Institution indicating that the ISPE Student Chapter has approval from the University.

1. Your Full Name *This question is required.

2. Your Email Address *This question is required. This question requires a valid email address.

3. Faculty Advisor Full Name as it Should Appear on the ISPE Website *This question is required.

4. Faculty Advisor Position, Credentials, and Name of Institution. In your letter of application, please include an introduction to the Faculty Advisor, including an explanation of why this person is capable of serving your organization and your advisor's involvement with ISPE. *This question is required.

6. Faculty Advisor Address: Street Address, City, State/Province, and Zip/Postal Code *This question is required.

7. Faculty Advisor Email Address *This question is required. This question requires a valid email address.

8. Faculty Advisor Phone Number *This question is required.

9. Name of Chapter, Including the Educational Institution
*This question is required.

10. Chapter Leadership, Email, and ISPE Membership Status

To be an active ISPE Student Chapter, 50% of the officers must be current ISPE members. The application is straightforward, and there is a special price for students. *This question is required.

Space Cell	Name	Email	ISPE Member (Yes or No)
President	President: Name	President: Email	President: ISPE Member (Yes or No)
Vice President	Vice President: Name	Vice President: Email	Vice President: ISPE Member (Yes or No)
Secretary	Secretary: Name	Secretary: Email	Secretary: ISPE Member (Yes or No)
Treasurer	Treasurer: Name	Treasurer: Email	Treasurer: ISPE Member (Yes or No)

11. Chapter President's Position and/or Current Studies *This question is required.

12. Chapter President Address, City, State/Province, Zip/Postal Code *This question is required.

13. Chapter President Phone Number

14. Anticipated Number of Student Chapter Members *This question is required.

15. Number of Anticipated Student Chapter Members that are ISPE Members

There is a policy requirement that 25% of Student Chapter members are also members of ISPE.

16. Please upload a signed letter from the University indicating that the ISPE Student Chapter has approval. The maximum file size is 750k. Allowable file types include png, gif, jpg, jpeg, doc, xls, docx, pdf, and txt. *This question is required.

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17. Please upload a letter from the Chapter President and Advisor that describes the student's interest, capacity, and plan for the chapter's pharmacoepidemiologic activities. The maximum file size is 750k. Allowable file types include png, gif, jpg, jpeg, doc, xls, docx, pdf, and txt. *This question is required.

File: {{filename}} delete

ISPE Student Chapter Application

ISPE Student Chapter Application Form