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Pharmacy Technicians

APPLICATION FOR LICENSE TO PRACTICE PHARMACY

    

Section 1 - Personal Information

Date of birth

                   

Section 2 - Contact Information

Section 3 – Education

Date Degree or Certificate Conferred:
       
Date Obtained:

Section 4 - Other Licences/Registration(s)


    
Expiration Date:
    
Expiration Date:

Section 5 - Impairment and/or Drug/Alcohol Addition(s)

  
  

Section 6 - Criminal Activity/Disciplinary Action

Note: Failure to disclose criminal history may result in the denial or your application, even if the records have been expunged.

  
  
  
  
If you answer "Yes" to ANY of the questions in Section 6, you must attach a letter of explanation and a CERTIFIED COPY of the court judgment in the case for EACH incident. If charges were dismissed, provide a letter from the appropriate agency confirming dismissal of the charges.

PLEASE ANSWER THE FOLLOWING QUESTIONS: YES NO

  
  
  
  
  

Section 7 – Upload any relevent attachments

Upload certificate or identity attachments:

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