Pharmacy Technician

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Instructions

You are applying for a pharmacy technician registration. The costs are $60-application fee, $40-Background Fee, $3-Transaction Fee for a total of $103.
Please have available your driver’s license and current photo within the last 6 months to upload during the process.

Demographics

* Last Name * First Name * Middle Name Maiden Name

* Address 1 Lot/Apt #
* City * State * Zip * County
* Phone # * SSN # * Date of Birth Cell Phone #
Click Here To Upload Photo (Do not upload Driver's license here)
(Please upload a 2x2 Passport
size photograph that is
less than 6 months old)
* Email * Sex * Are you a United States Citizen? * Document Type * Citizenship document

Regulatory Questions

1. Have you been arrested of a felony or misdemeanor, excluding minor traffic violations?


Background Check Disclosure

      Alabama Board of Pharmacy (“the Board”) may obtain information about you from a third party background screening companies for licensing purposes.



     These searches will be conducted by Know My Hire, 28577 Hwy. 5 Woodstock, AL | 877.893.5669 | knowmyhire.com



I also understand that iGovSolutions is only a technology provider and the Board is the end-user of the background check.






Fair Credit Reporting Act (FCRA) Rights

WELCOME

Please click here to download the Fair Credit Reporting Act (FCRA) .


Notice Regarding Background Investigation

ACKNOWLEDGMENT AND AUTHORIZATION FOR BACKGROUND CHECK

     In connection with your application with (The Alabama Board of Pharmacy) (“Requestor”), notice is hereby given that a consumer report and/or investigative consumer report may be obtained from a consumer reporting agency for employment purposes. Thus, you may be the subject of a “consumer report” and/or “investigative consumer report” as defined by the Fair Credit Reporting Act (15 U.S.C. § 1681). These reports may contain information about your character, general reputation, personal characteristics and mode of living, whichever are applicable. They may involve personal interviews with sources such as your neighbors, friends or associates. The report may also contain information about you relating to your criminal history, credit history, driving and/or motor vehicle records, social security verification, workers’ compensation claims (after a conditional offer of employment has been made), verification of your education or employment history or other background checks. You have the right, upon written request made within a reasonable time after the receipt of this Notice, to request disclosure of the nature and scope of any investigative consumer report prepared contacting KnowMyHire, 28577 Hwy. 5, Woodstock, AL 35188 – Phone: 877.893.5669. For information about KnowMyHire’s privacy practices see www.KnowMyHire.com. The scope of this Notice and Authorization is not limited to the present and, if you are hired will continue throughout the course of your employment and will allow the Requestor to conduct future screenings for retention, promotion or reassignment, as permitted by law and unless revoked by you in writing. The Requestor also reserves the right to share background investigation results with any third-party companies for whom you will be placed to work as a representative of the Requestor. By e-signing below, I acknowledge receipt of above Notice Regarding Background Investigation and a copy of the federal notice entitled, “A Summary Of Your Rights Under The Fair Credit Reporting Act” and certify that I have read both documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by the Requestor at any time after receipt of this Authorization and throughout the course of my employment, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer or insurance company to furnish any and all background information requested by KnowMyHire, 28577 Hwy. 5, Woodstock, AL 35188 – Phone: 877.893.5669, www.KnowMyHIre.com, another outside organization acting on behalf of the Requestor, and/or the Requestor. I agree that a facsimile (“fax”), electronic, or photographic copy of this Authorization shall be as valid as an original.



New York applicants only : You have the right to inspect and receive a copy of any investigative consumer report requested by Requestor by contacting KnowMyHire, 28577 Hwy. 5, Woodstock, AL 35188, Phone: 877.893.5669. By e-signing below, you acknowledge receipt of a copy of Article 23-A of the New York Correction Law.

Washington State applicants only : You have the right to request from KnowMyHire a written summary of your rights and remedies under the Washington Fair Credit Reporting Act

Minnesota and Oklahoma applicants only : Please check the box below if you would like to receive a copy of a consumer report if one is obtained by the Requestor.

California applicants only : By e-signing below, you also acknowledge receipt of the “NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW”. Please check this box if you would like to receive a copy of an investigative consumer report or consumer credit report free of charge, if one is obtained by the Requestor and you have a right to receive such a copy under California Law.



E-Signature : Date : 11/22/2017

Preview

Affirm pay and submit

  • I understand that I must comply with the provisions of the Alabama Practice Act, Rules of the Board and all other applicable statues and rules.

  • I affirm that all information provided herein is true and correct and I recognize that providing false information may result in disciplinary action.

* Electronic Signature :
Date : 11/22/2017

(Board of Pharmacy charge will appear as "ALA ST BOARD OF PHARM". Background check fee and convenience fee will appear as "iGov e Pay LLC" on your statement.)

*Amount Due (in $) : Background Check Fee (in $) : *Transaction Fee (in $) : *Total (in $) :
* Person's Name on Card: *Select Debit or Credit : *Card Type :
*Card # : *Expiration Date :
* Security Code :

(Board of Pharmacy charge will appear as "ALA ST BOARD OF PHARM" and convenience fee will appear as "iGov e Pay LLC" on your statement.)
 

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