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AFFIDAVIT OF EXPERIENCE PHARMACIST INTERN TRAINING PROGRAM
State Form 26877 (R5 / 2-06)

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

INSTRUCTIONS:

1. Affidavit to be completed by LICENSED SUPERVISING PHARMACIST of the Pharmacist Interns training period. 2. Practical experience time must be listed below on a calendar week basis showing actual time served each week. 3. Return form to: Professional Licensing Agency 402 West Washington Street, Room W072 Indianapolis, Indiana 46204

IMPORTANT NOTICE TO PERSONS WHO HAVE AFFIDAVITS EXECUTED OUTSIDE OF INDIANA

Each affidavit taken outside of this state must be accompanied by certification from the Board of Pharmacy in the state where served that such experience time is acceptable to that Board.

State in which affidavit executed

County in which affidavit executed

Date affidavit executed (month, day, year)

LICENSED PHARMACIST
Name of licensed pharmacist (first, middle, last) Name of pharmacy employed Address of pharmacy employed (number and street, city, state, and ZIP code) State certified in License number Permit number of pharmacy Telephone number

(

)

PHARMACIST INTERN
Name of intern (first, middle, last) Address of intern (number and street, city, state, and ZIP code) Permit number of intern

WEEK(s) EMPLOYED (ending on) Month Day Year

NUMBER OF HOURS EMPLOYED EACH WEEK

WEEK(s) EMPLOYED (ending on) Month Day Year

NUMBER OF HOURS EMPLOYED EACH WEEK

TOTAL number of weeks employed

TOTAL number of hours employed

TOTAL length of employment (month, day, year) From To

The above employment information was taken from payroll or other records which are kept at (pharmacy name):

AFFIDAVIT

On this day, I certify that I am a licensed pharmacist holding the certificate number listed above in the state certified in, and that the above named pharmacy intern, located at the address indicated, was in my employ, compounding and filing prescriptions for medical practitioners under my supervision for the total number of hours, and length of employment listed above for the above named pharmacy. I solemnly swear, or affirm that the statements give above are true and correct to the best of my knowledge.
Signature of licensed pharmacist Date signed (month, day, year)