Application for Registration as a Pharmacy Technician Trainee

Personal Information


First Name:	Middle Initial:	Last Name:	Suffix:
Maiden Name:	Gender:	Date of Birth:	Social Security Number:
Place of Birth:
Upload a 3x4 inch head and shoulders photograph. Click here for recommendations on uploading files.

Education


Select one:	High School Graduate
	General Education Development (GED) Certificate
	Enrolled in High School Program


Graduate of (High School):		Year:
City:	State:	Zip:
General Education Development (GED) Certificate Issued by Board of Education in:
County:	State:	Year:
Enrolled in a high school program at:
High School Name:	Expected Graduation Year:

Qualifications

I certify that I am either:

Enrolled in a competency-based pharmacy technician education and training program of a learning institution or training center as approved by legislative rule of the board

Working in a 500 hour pharmacy provided, on-the-job, competency-based education and training program approved by the board

Obtained a national certification as a pharmacy technician and have practiced in another jurisdiction for at least one year