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

Pharmacist Form 5 - Application For A Limited (Intern) Permit - 2016 Page 4

SECTION II: CERTIFICATION OF EDUCATION PROGRAM

(To be completed only for applicants enrolled in or graduated from an ACPE or CCAPP (since 1993) accredited pharmacy program.) Graduates of non-

accredited programs do not need to complete Section II.

INSTRUCTIONS TO REGISTRAR:

Complete the enrollment statement below. Be sure to sign and date the certification and

forward this form directly to the Office of the Professions at the address at the end of the

form.

ENROLLMENT STATEMENT OF COLLEGE OR SCHOOL OF PHARMACY

(To be certified by the college for students who have COMPLETED at least the first professional year of study.)

I hereby certify that ________________________________________________________________________________

is/was a student at ________________________________________________________________________________

(Name of school)

and is/was a member in good standing of the Class of __________ .

Date entered program: _______ / _______ / _______

mo.

day

yr.

Date graduated from program: _______ / _______ / _______

mo.

day

yr.

CERTIFICATION

I hereby certify that to the best of my knowledge and belief the information in Section II is a true statement of the record of the

professional education of the individual named on this form.

Signature _________________________________________________________ Date _______ / _______ / _______

mo.

day

yr.

Print or type name _________________________________________________

Title or official position _____________________________________________

Institution _________________________________________________________

(COLLEGE SEAL)

Location __________________________________________________________

Telephone __________________________ ______________________________

Fax ______________________________________________________________

E-mail ____________________________________________________________

Mail this form and

New York State Education Department, Office of the Professions, PO Box 22063, Albany, NY 12201. Do Not Send Cash. Please

appropriate fee to:

make check or money order payable to the New York State Education Department

Pharmacist Form 5, Page 4 of 4, Rev. 6/16

Pharmacist Form 5 - Application For A Limited (Intern) Permit - 2016 Page 4