Pharmacist Immunization Certification Form - Application For Certification - New York The State Education Department

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Department Use Only
The University of the State of New York
Pharmacist Immunization
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Certification Form
Division of Professional Licensing Services
Application for Certification
Applicants Must Complete All Pages Of This Application In Ink
Complete the entire form and submit it with the $100 fee for certification and any other required
documentation directly to the Office of the Professions at the address at the end of this form. Your
signature on this form must be notarized by a Notary Public.
$100
20
I P
Date Certified
1
2.
Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
Initials
2
3.
Birth Date
Month
Day
Year
6.
5
Telephone/E-Mail Address
3
4.
Print Name Exactly As It Appears On Your License
Daytime phone
Last
Area Code
Phone
First
E-mail Address
(please print clearly)
Middle
4
5.
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
6
6.
New York State pharmacist license number: ______________________ Registration expiration date: ________ / ________ / ________
mo.
day
yr.
Or, if you recently graduated from an ACPE accredited program
College of Pharmacy: _______________________________________________ Date of graduation: ________ / ________ / ________
mo.
day
yr.
7
8.
I have attached a copy of an approved course completion certificate in immunization.
Yes
No
If you are a recent graduate of a NYS ACPE accredited program and you completed the immunization program as part of the
college curriculum, please provide the following:
Name of college attended: ___________________________________________________________________________________
Date(s) of program: _________________________________________________________________________________________
I have attached a copy of a current valid course completion card in Basic Life Support (BLS/CPR) or its equivalent.
Yes
No
I have been actively administering immunizations in other state(s).
Yes*
No
*If yes, submit documentation (a signed letter with name of state, time period, and that you have been administering immunizations
is sufficient).
Pharmacist Immunization Certification Form, Page 1 of 2, Rev. 11/13

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