Free 12567.FH11 - Indiana

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APPLICATION FOR PHARMACIST INTERN REGISTRATION
State Form 12567 (R9 / 4-07) Approved by State Board of Accounts, 2007

INSTRUCTIONS: Please type or print legibly.

INDIANA BOARD OF PHARMACY PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2067 Fax: (317) 233-5559 E-mail: [email protected]

MANDATORY DISCLOSURE OF U.S. SOCIAL SECURITY NUMBER mandatory for the purpose of complying with IC 25-1-5-8 and IC 4-1-8-1 which provide that the Indiana Department of Revenue may obtain your Social Security number from the Professional Licensing Agency for tax enforcement purposes. In addition, disclosing such number is mandatory in order for the licensing board or committee to comply with the requirements of the federal National Practitioner Data Bank and the Healthcare Integrity and Protection Data Bank 42 U.S.C. § 1320(a)-7e(b), 5 U.S.C. § 552a, 45 CFR Part 60.1, and 45 CFR Part 61.

* Pursuant to Section 7 of the Privacy Act of 1974, you are hereby given notice that disclosure of your U.S. Social Security number on your application is

Failure to disclose your U.S. Social Security number will result in the denial of your application. Application fees are not refundable. FOR OFFICE USE ONLY APPLICATION FEE DATE FEE PAID (month, day, year) One (1) photograph required. DATE OF ISSUANCE (month, day, year) REGISTRATION NUMBER RECEIPT NUMBER CM Recent head and shoulder 2 X 2 photo must be attached to application. Photo must be of passport quality.

DO NOT WRITE ABOVE THIS LINE INFORMATION ABOUT THE APPLICANT
Name of applicant (last, first, middle) Address (number and street, city, state, and ZIP code) Date of birth (month, day, year) Telephone number Place of birth (city, state) E-mail address If Yes, where? If No, do you plan to enroll in or are you a graduate of a college of pharmacy? If Yes, when and where? Social Security number * Maiden name of applicant (if applicable)

(

)

Are you enrolled in a college of pharmacy?

Yes

No

Yes

No

If your answer is Yes to any of the following, explain fully in a signed and notarized statement, including all related details and documentation. Include violation, location, date and disposition. Falsification of any of the following is grounds for permanent revocation of a registration issued pursuant to this application.

1. Has disciplinary action ever been taken regarding any health license, certificate, or registration you hold or have held in any state or country? 2. Have you ever been denied a license, certificate, registration, or permit to practice as a pharmacist intern or any regulated health occupation in any state or country? 3. Are there any charges pending against you regarding a violation of any Federal, State or Local law relating to the use, manufacturing, distribution or dispensing of controlled substances, alcohol, or other drugs? 4. Have you ever been convicted or pled guilty or nolo contendre to: i. A violation of any Federal, State, or Local law relating to the use, manufacturing, distribution, or dispensing of controlled substance, alcohol, or other drugs? ii. To any offense, misdemeanor or felony in any state (except for minor violations of traffic laws resulting in fines?) 5. Have you ever been treated for drug or alcohol abuse?

Yes Yes Yes Yes Yes Yes

No No No No No No

CERTIFICATE OF ENROLLMENT OR GRADUATION IN PHARMACY EDUCATION

NOTE TO APPLICANT: The certificate below must be completed and signed by the Secretary or Dean of the School or College of Pharmacy of which you are currently enrolled or a graduate. If you are a graduate of a School or College of Pharmacy outside of the United States, then you do not need this certificate completed; you are required to submit a notarized copy of your FPGEC Certificate. This is to certify that __________________________________________________________________________ is enrolled / a graduate of ___________________________________________________________________________________________________________ .
Name of school or college of pharmacy Number of years pharmacy Number of years pre-pharmacy City, State of Indiana Date (month, day, year)

Signature of Secretary or Dean

(SEAL)

SPONSORS STATEMENT AND AFFIDAVIT

To the Indiana Board of Pharmacy: I, ______________________________________________________ , of

____________________

County of ________________________________________ , State of Indiana, do hereby make the following statement for the benefit of ______________________________________________________________ who is an applicant for registration as a pharmacist intern.
Name of Indiana Licensed Pharmacist Place of employment Address (number and street, city, state, and ZIP code) License number Pharmacy permit number

Please check one only:

On this day, I certify that I am a licensed pharmacist holding the license number listed above in Indiana and that the above named pharmacist intern will be in my employ, compounding, and filling prescriptions for medical practitioners under my supervision at the above named pharmacy. On this day, I certify that the applicant named herein is enrolled in a college of pharmacy and will be entering an externship program. Within the program, the applicant will be filling and compounding prescriptions under the direct supervision of a licensed pharmacist in a licensed pharmacy. I solemnly swear or affirm that the statements given above are true and correct to the best of my knowledge.
Signature of Indiana Licensed Pharmacist Date (month, day, year)

APPLICATION AFFIRMATION

I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete and correct.
Signature of applicant Date (month, day, year)

AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby authorize, request, and direct any person, firm, officer, corporation, association, organization or institution to release to the Professional Licensing Agency, or the Indiana Board of Pharmacy, any files, documents, records or other information pertaining to the undersigned requested by the Agency, or the Board, or any of its authorized representatives, in connection with processing my application for licensure. I hereby release the aforementioned persons, firms, corporations, associations, organizations, and institutions from any liability with regard to such inspection or furnishing of any such information. I further authorize the Professional Licensing Agency, or the Indiana Board of Pharmacy, to disclose to the aforementioned persons, firms, officers, corporations, associations, organizations, and institutions any information which is material to my application, and I hereby specifically release the Agency, and the Board from any and all liability in connections with such disclosures. A photostatic copy of the authorization has the same force and effect as the original.
AFFIRMATION

I hereby swear or affirm that I have read the above statements and agree to same.
Signature of applicant Date signed (month, day, year)