Pharmacist Form 5 - Application For A Limited (Intern) Permit

Pharmacist Form 5 - Application For A Limited (Intern) Permit - 2016

The University of the State of New York

Department Use Only

Pharmacist Form 5

THE STATE EDUCATION DEPARTMENT

Office of the Professions

Division of Professional Licensing Services

Application for Limited (Intern) Permit

$70

Permit Number

APPLICANT INSTRUCTIONS

Date Issued

Complete Section I in ink. Be sure to sign and date item 11. You must sign and date the Affidavit on

this form in the presence of a Notary Public. Send this form, along with the $70 fee, to your school and

ask the Registrar to certify your enrollment. The form must then be sent directly from your school to the

Office of the Professions at the address at the end of this form in a sealed official school envelope.

Date Expires

(5 years from date of issue)

SECTION I: APPLICANT INFORMATION

Initials

Social Security Number

(Leave this blank if you do not have a U.S. Social Security Number)

Telephone/E-Mail Address

Daytime Phone

Birth Date

Month

Day

Year

Area Code

Phone Number

E-Mail Address (Please print clearly)

Print Name

Last

First

Middle

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

COLLEGE NAME: ____________________________________________________________________________________________________

Check one:

B.S. /BPharm degree

PharmD

GRADUATION DATE: _____ / _____ / _____

mo.

day

yr.

Pharmacist Form 5, page 1 of 4, Rev. 6/16

Pharmacist Form 5 - Application For A Limited (Intern) Permit - 2016

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