Pharmacist Form 4b - Certification Of Completion Of Pharmacy Practice Residency Competencies - New York The State Education Department

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The University of the State of New York
Pharmacist
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Form 4B
Division of Professional Licensing Services
Certification of Completion of
Pharmacy Practice Residency Competencies
Applicant Instructions
This form may be used by applicants who attain competence within a pharmacy that oversees residencies. The program must be accredited
by an approved national accrediting body acceptable to the Department. Please confirm with your residency program director that the
residency program is participating in this route to licensure.
1.
Complete Section I. In item 3, enter your name as it appears on your Application for Licensure (Form 1). Be sure to sign and date item 6.
2.
Forward all 3 pages of this form to your residency program director and ask that they complete Section II.
3.
Measurement standards (see sample provided on page 3) as well as detailed information on measurement standards utilized for
assessment of competencies must be submitted by the pharmacist residency program director along with this form.
The residency program director must submit this form as well as any other required information directly to the Office of the
Professions at the address at the end of this form. This form will not be accepted if submitted by the applicant.
Section I: Applicant Information
2
1.
1
Social Security Number
2.
Birth Date Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
3.
3
Print Name As It Appears on Your Application for Licensure (Form 1)
Last
First
Middle
4
4.
Mailing Address
(You must notify the Department promptly of any address or name changes.)
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
5
5.
Name of the institution where you are enrolled in a residency program (please type or print):
_____________________________________________________________________________________________________________
Name of accredited residency program:
_____________________________________________________________________________________________________________
Dates of residency program: _______ / _______ / _______ to: _______ / _______ / _______
mo.
day
yr.
mo.
day
yr.
6
6.
I request and give my permission to the institution listed in item 5 above to complete this form and mail it to the New York State
Education Department, and to release any other information requested by the State Education Department in connection with my
application for licensure.
Applicant's Signature: ______________________________________________________________ Date:_______ / _______ / _______
mo.
day
yr.
Pharmacist Form 4B, Page 1 of 2, Rev. 2/14

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