Pharmacist License Application Form - 2000 Page 3
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3MEMBERSHIP IN PHARMACY ASSOCIATIONS:
DATES
NAME AND ADDRESS
OFFICE HELD
SPECIAL PROJECTS
OF ASSOCIATION
(IF ANY)
OR COMMITTEES
Began
Ended
PERSONAL DATA
If any of the following answers are yes, please explain in detail in affidavit form on a separate sheet and provide any supporting documents.
YES
NO
1. Have you been called before any state board for any reason concerning any violation of the pharmacy laws or
unethical conduct? ...............................................................................................................................................
2. Have you been denied a certificate by, or the privilege of taking an exam before any state pharmacy board? ..
3. Have you had a license to practice as a registered pharmacist revoked, suspended, or restricted?...................
4. Have you been charged or convicted of a violation of a U.S. or state statute or regulation, excluding minor traffic
violations? ............................................................................................................................................................
5. Have you been addicted to or excessively used alcohol, narcotics, barbiturates, or habit-forming drugs within
the last five years? ...............................................................................................................................................
6. Are you now or have you been treated for emotional or mental illness, drug addiction, or alcoholism within the
last five years? .....................................................................................................................................................
7. Have you applied for and been denied a DEA number? ......................................................................................
8. Have you surrendered your DEA number for any other reason than routine matters? ........................................
9. Have you been charged with or convicted of a violation of any federal or state controlled substance law?........
10. Are there any charges involving any of the above items pending against you?...................................................
I HEREBY CERTIFY that the information contained in this application is true and correct to the best of my knowledge. I further certify that
all credentials supplied by me are true and correct and that the photograph which appears below is a true likeness of myself taken within
the past sixty (60) days. I understand that any false information or falsification of credentials may result in failure to obtain a license to
practice as a registered pharmacist in the State of Alaska.
Signature of Applicant
SUBSCRIBED AND SWORN to before me, a notary public, in and for
the State of
PHOTOGRAPH
this _________ day of ___________________________ 20
Notary Public
My Commission Expires:
NOTARY SEAL MUST OVERLIE A
PORTION OF THE PHOTOGRAPH
08-4032 (Rev. 7/00)
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