Free 51635.FH11 - Indiana

APPLICATION FOR CERTIFICATION AS A PHARMACY TECHNICIAN (CPT)
State Form 51635 (R2 / 9-08) Approved by State Board of Accounts, 2008

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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] Web: www.pla.IN.gov

* 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 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 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 USC §552a, 45 CFR Part 60.1, and 45 CFR Part 61. 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 / permit fee Certificate number issued Date fee paid (month, day, year) Permit number issued Receipt number Date issued (month, day, year)

DO NOT WRITE ABOVE THIS LINE
Please check all that apply: I have completed a program of education and training approved by the Board. (Please include verification completion of the program and / or training.) I have passed a certification examination offered by a nationally recognized certification body, approved by the Board. (Please include a copy of your certificate.) If you did not check at least one of the above, you must apply for a Pharmacy Technician-in-Training Permit. I am applying for a Pharmacy Technician-in-Training Permit: Yes No
Name of applicant (last, first, middle, maiden or previous) Address (number and street or rural route, city, state, and ZIP code) Home telephone number (include area code) Work telephone number (include area code) Email address Social Security number *

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Place of birth (city and state)

Date of birth (month, day, year)

Have you graduated from high school or do you hold a General Equivalency Diploma (GED)?

Yes

No

If your answer is "Yes" to any of the following, explain fully in a signed and notarized statement, including all related details. Include the violation, location, date and disposition. If malpractice, provide name(s) of plaintiff(s). Letters from attorneys or insurance companies are not accepted in lieu of your statement. Falsification of any of the following is grounds for permanent revocation of a license or permit issued pursuant to this application. 1. Has disciplinary action ever been taken regarding any health license, certificate, registration or permit that you hold or have held? 2. Have you ever been denied a license, certificate, registration or permit to practice any regulated health occupation in any state (including Indiana) or country? 3. Are you now being, or have you ever been treated for drug or alcohol abuse? 4. Have you ever been convicted of, pled guilty or nolo contendre to, or are formal charges pending for: A. A violation of any Federal, State or local law relating to the use, manufacturing, distribution or dispensing of controlled substances? B. Any offense, misdemeanor or felony in any state? (Except for minor violations of traffic laws resulting in fines.) 5. Have you ever been denied employment in a pharmacy, or had such employment revoked, suspended or subjected to any restriction, probation or other type of discipline of limitations? 6. Have you ever had a civil action filed against you for breach of your professional duties? 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 signed (month, day, year)

Yes Yes Yes Yes Yes Yes Yes

No No No No No No No

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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 their 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 to 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 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 signed (month, day, year)

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