Pharmacist License Application Form - 2000
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3PHA
STATE OF ALASKA
FOR OFFICE USE ONLY
DEPARTMENT OF COMMUNITY AND ECONOMIC DEVELOPMENT
DIVISION OF OCCUPATIONAL LICENSING
BOARD OF PHARMACY
P.O. BOX 110806
JUNEAU, ALASKA 99811-0806
(907) 465-2589
E-mail: license@dced.state.ak.us
PHARMACIST LICENSE APPLICATION
THIS APPLICATION MUST BE COMPLETED IN FULL. If any section does not apply, please write N/A in the space provided. TYPE OR
PRINT IN INK ALL INFORMATION. A bank draft, certified check, or money order MUST accompany this application.
Nonrefundable Application Fee:
$ 50.00
License Fee:
$180.00
Wall Certificate Fee:
$ 20.00 (optional)
Temporary License Fee:
$ 50.00
I HEREBY MAKE APPLICATION for licensure to practice pharmacy in the State of Alaska by:
Examination
Credentials
Score Transfer
IF APPLYING FOR LICENSURE BY CREDENTIALS through NABP, upon what state license is the application based?
State:
License Number:
Issue Date:
Expiration Date:
Name
Social Security Number
Address
Street or P.O. Box
City
State
Zip Code
Work Telephone
Home Telephone
Place of Birth
Date of Birth:
Sex:
Citizen of the United States
By Birth
By Naturalization, since
Have you ever been known by any other name?
No
Yes
(If name change was by court order, enclose a certified copy of such order.)
Are you fluent in reading, writing, and speaking in the English language?
Yes
No
GENERAL EDUCATION
High School
City and State
Year
College or University
City and State
Dates Attended
Degree Awarded
PHARMACY EDUCATION
Name of School
City and State
Dates Attended
Degree Awarded
Foreign-Trained Graduates: FPGEC Certification Number
Date Received
CONTINUED ON REVERSE SIDE
08-4032 (Rev. 7/00)
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