Free 51636.FH11 - Indiana

APPLICATION FOR REPEAT EXAMINATION FOR PHARMACIST LICENSE
State Form 51636 (R / 5-06) Approved by State Board of Accounts, 2006

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INDIANA BOARD OF PHARMACY PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, IN 46204 Telephone: (317) 234-2067 E-mail: [email protected] www.pla.IN.gov

APPLICATION FEE DATE FEE PAID (month, day, year) RECEIPT NUMBER LICENSE NUMBER DATE ISSUED (month, day, year) APPLICANT Attach one (1) Passport type quality photograph of yourself taken within the last eight weeks.

* The request for your Social Security number is MANDATORY according to IC 4-1-8-1. DO NOT WRITE ABOVE THIS LINE

APPLICANT INFORMATION
Name of applicant (last, first, middle, maiden) Social Security number * Address (number and street or rural route) City, state, and ZIP code Telephone number (daytime) E-mail address

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Name of school or college of pharmacy Date of graduation (month, day, year) Date of last examination (month, day, year) Number of times exam has been taken

PLEASE CHECK WHICH EXAMINATION YOU WILL BE REPEATING

NAPLEX

MPJE

If your answer is yes to any of the following, explain fully in a sworn affidavit, including all related details. Describe the event including location, date and disposition. If malpractice, 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. Since you last applied: 1) 2) 3) 4) Has disciplinary action ever been taken regarding any health license, certificate, registration or permit that you hold or have held in any state (including Indiana) or country? Have you ever been denied a licensure, registration or certification in any state (including Indiana) or country? 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? Have you ever been convicted of, pled guilty or nolo contendre to any of the following: a. A violation of 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?) Have you ever been denied staff membership or privileges in any pharmacy or have any privileges been revoked, suspended or subjected to any restrictions, probation or other type of discipline or limitations? Have you ever had a malpractice judgment against you or settled any malpractice action? Have you ever been treated for drug or alcohol abuse?
APPLICATION AFFIRMATION

Yes Yes Yes

No No No

Yes Yes

No No

5) 6) 7)

Yes Yes Yes

No No No

I hereby swear or affirm under the penalties of perjury, that the above statements made in this application including all attachments 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 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)