Intern/Extern Application

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Demographics

Last Name
First Name
Middle Name
Maiden Name
Email
Phone (Mobile)
Phone (Home)
Phone (Work)
SSN
DOB
Address
City
State
Zip
County
Date enrolled in Pharmacy
(You must be enrolled in a school of pharmacy pursuing a pharmacist’s degree. Do not fill out this application if you are enrolled in a pharmacy technician program.)
Name of Pharmacy School
Pharmacy School City
Pharmacy School State
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(Please upload a 2x2 Passport size photograph that is less than 6 months old)
* Are you US citizen?



Education Details

INFORMATION ABOUT PRE-PHARMACY EDUCATION

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OTHER STATE LICENSE INFORMATION

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1
Have you completed requirements for pharmacy degree?
Expected date of graduation:

Regulatory Questions

Have you ever been arrested and or convicted of a felony or misdemeanor, excluding minor traffic violations?
Have you ever been arrested and/or convicted of violating any laws regulating controlled substances or prescription legend drugs?
Have you ever been licensed, permitted, or registered in any other state as a pharmacist, pharmacy technician or any other position requiring a license, permit or registration from a pharmacy board or requiring a permit involving dispensing controlled substances?
Are there currently any pending investigations or charges regarding any license, permit or registration issued to you?
Are you currently or have you ever been charged with a substance abuse violation or been in a substance abuse treatment program?
Has any final judgement been entered or settlement reached resulting from a claim or action for damages caused by any error, omission, or negligence in the performance of any pharmacy or pharmaceutical professional services by the Applicant or any Owner, Officer, Member, Director, Manager, Partner or by you?
Have you or any entity you own/owned in whole or part ever been denied any license, permit, registration, certification or like authority by any board of pharmacy or any other occupational or regulatory board? If so, list state, type of license, etc., the occupation or profession and reason for denial.
Have you or any entity you own/owned in whole or part ever surrendered or failed to renew any license, permit, registration, certification or like authority issued by any board of pharmacy or any other occupational or regulatory board? If so, list state, type of license, etc., the occupation or profession and reason for the surrender or failure to renew.
Has any license, permit, registration, certification or like authority issued to you or any entity you own/owned in whole or part by any board of pharmacy or any other occupational or regulatory board been sanctioned or subject to discipline in any way? If so attach copy of the discipline.

Please note If you answer “yes” to question 1 or 2, upload final order and documentation from that Board of Pharmacy or federal government.
If you answer yes to question 4, upload your arrest report, case disposition and statement. This can be uploaded as a single document.


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Affirm and Submit


I understand that I must comply with the provisions of the Alabama Pharmacy Practice Act, Rules of the Board and all other applicable statutes and rules. That all information provided herein is true and correct and I recognize that providing false information may result in disciplinary action.

* Electronic Signature :
      
 

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