Free 36028.FH11 - Indiana

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APPLICATION FOR PHARMACIST'S LICENSE
State Form 36028 (R13 / 8-07)

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, IN 46204 Telephone: (317) 234-2067 E-mail: [email protected] Web: www.pla.IN.gov

* Your Social Security number is being requested by this state agency in accordance with
I.C. 4-1-8-1. Disclosure is mandatory, and this record cannot be processed without it. FOR OFFICE USE ONLY APPLICATION FEE DATE FEE PAID (month, day, year) RECEIPT NUMBER LICENSE NUMBER ISSUED DATE LICENSE ISSUED (month, day, year)

One Photograph Required Recent head and shoulder 2"x2" photos must be attached to application. Photos must be of passport quality.

DO NOT WRITE ABOVE THIS LINE

Please indicate which test(s) you wish to take:

MPJE

NAPLEX

Score Transfer

APPLICANT INFORMATION
Name of applicant (last, first, middle) Maiden name (if applicable)

Address (number and street)

E-mail address

City, state, and ZIP code

Social Security number *

Date of birth (month, day, year) Place of birth (state)

County

Telephone number

(
Total pharmacist intern hours Pharmacist intern registration number State issued

)
Date issued (month, day, year)

Name of school or college of pharmacy

Number of years attended

Date graduated (month, day, year)

I,

, above named, hereby swear or affirm under the penalties of perjury that the statements made by me in this application for licensure as a Pharmacist by examination are true and correct. I further pledge myself to practice the profession of pharmacy with dignity, integrity and honor and to conduct myself at all times in an ethical manner should I be granted the privilege of licensure as a pharmacist in the State of Indiana.
Date signed (month, day, year)

Signature of applicant

If your answer is "Yes" to any of the following, explain fully in a sworn affidavit, including all related detail. Describe the event including the location, date and disposition. If you have had a malpractice judgment , provide the name of the plaintiff. Falsification of any of the following is grounds for permanent revocation of a license or permit issued pursuant to the application. 1. Has disciplinary action ever been taken regarding any health license, certificate or permit 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 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: A. A violation or any Federal, State or local law relating to the use, manufacturing, distribution or dispensing of controlled substances, alcohol or other drugs? B. To any offense, misdemeanor or felony in any state? (Except for minor violations of traffic laws resulting in fines) 5. Have you ever been denied staff membership privileges in any pharmacy or have any privileges been revoked, suspended or subjected to any restrictions, probation or other type of discipline or limitations? 6. Have you ever had a malpractice judgment against you or settled any malpractice action? 7. Have you ever been treated for drug or alcohol abuse? AUTHORIZATION FOR RELEASE OF INFORMATION Yes Yes Yes No No No

Yes Yes Yes Yes Yes

No No No No No

I hereby authorize, request and direct any person, firm, officer, corporation, association, organization or institution to release to the Professional Licensing Agency and the Indiana Board of Pharmacy any files, documents, records or other information pertaining to undersigned requested by the Agency or Board, or any of its authorized representatives in connection with processing application for licensure as a pharmacist. I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations, and institutions from any liability with regard to such inspection or furnishing of any information. I further authorize the Professional Licensing Agency and 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 connection with such disclosures. A photostatic copy of this 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 (month, day, year)

APPLICATION FOR EXAMINATION FOR PHARMACIST'S LICENSE CERTIFICATE OF COMPLETION
Part of State Form 36028 (R13 / 8-07)

Approved by State Board of Accounts, 2007 CERTIFICATE OF COMPLETION OF PHARMACY EDUCATION B.S. Pharmacy Pharm. D.

INDIANA BOARD OF PHARMACY PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, IN 46204

I hereby certify that ______________________________________________________________________________ was admitted to the degree program in the School of Pharmacy at __________________________________________________________________________________ on ___________________ and graduated with the professional degree noted above on ______________________________ . The candidate has completed ________________________ years as a student in the School. There is evidence in our permanent records that the person certified here has met all the requirements of Indiana Code 25-26-13-11(a) and (a)(4) by completing the professional degree program noted here, and has completed ______________ clock hours of practical experience as stated in 856 IAC 1-3.1-7 in connection with the degree program at the School _________________________________________________________________________ . Date of Certification _________________________________________ Signed ____________________________________________________ __________________________________________________________________ School of Pharmacy

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