Student Application Form

Applicant Information

Educational Background

Additional Information

Availability

Work Experience

Full Name

Any Previous Last Name(s):

Date of Birth

Sex

Male Female

Mailing Address: Street, City, State, and Apt.

Primary Phone

ALT Phone

High School Diploma or G.E.D.?

Yes No

If no, please explain

Name of High School

Graduation Year

Diplomas and transcripts from foreign countries must be evaluated for US equivalency by a recognized credential evaluation agency such as the Center for Educational Documentation (CED), www.cedevaluations.com.

College Name

College Address

Date of Attendance

Graduation Date

Degree Received

Have you completed any other relevant coursework or programs?

Yes No

If yes, please specify

Are you a U.S. Citizen?

Yes No

Have you been convicted of a felony?

Yes No

Have you been convicted of any drug related felony?

Yes No

If YES, at the time of registration with the Board of pharmacy, the following is required: A typewritten 8 ½” by 11” sheet(s) of paper which provides dates and details describing the circumstances related to the matters on the matter(s); certified copies of court documents of any convictions (defined as any plea that is accepted by a court); and completion of a Criminal Offender Record Information Request (CORI) Form (available at pcshq.com). (Note: Conviction of a crime does not necessarily bar registration; however, failure to disclose may result in denial of application or other disciplinary action by the Board.)

Are you available for part-time or full-time study?

Part-Time Full-Time

Please indicate your preferred class schedule

Weekdays Weekends Evenings

Have you worked in a healthcare or pharmacy setting before?

Yes No

If yes, please describe your experience

Acceptance

I certify that the information provided in this application is true and complete to the best of my knowledge.

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