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
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 denied a pharmacy related license or permit? If so, what type of license and in which State?
Have you ever surrendered your pharmacist, intern/extern or technician license, or had it suspended or revoked, or had other disciplinary action taken by this board, another state or the federal government ?
Have you ever been charged with a substance abuse vialotion or been in a substance abuse treatment program
Have you ever been arrested and/or convicted of a felony or misdemeanor, excluding minor traffic convictions?
Have you ever been arrested and/or convicted of violating any laws regulating controlled substances or prescription legend drugs?

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 questions 3 or 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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