Intern Experience Affidavit Or Hours Log
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1
2Oregon Board of Pharmacy
800 NE Oregon Street Suite 150
Portland, Oregon 97232
Phone: (971) 673-0001
INTERN EXPERIENCE AFFIDAVIT / HOURS LOG
INSTRUCTIONS:
1.
A separate affidavit must be completed when:
2.
Affidavit to be used for Oregon experience only.
a. The intern changes preceptors.
Remember to have Preceptor sign hours log as well
b. A new calendar year begins.
as have Intern hours Notarized.
c. The intern changes locations.
TO BE COMPLETED BY PRECEPTOR (Please print or type):
Preceptor's Name
Preceptor Lic #
Supervising
Pharmacist(s)
Pharmacy Name
Phone #
Pharmacy Address
City, State, Zip
This is to certify that
(name of intern) was employed under
my supervision during the time set forth as follows:
From
to
= Total hours worked
month
/
day
/
year
month
/
day
/
year
Preceptor signature
Date
TO BE COMPLETED BY INTERN (Please type or print):
Intern Name
License number
Address
Phone number
City, State, Zip
I have reviewed the information included in this affidavit and agree that it accurately covers my internship experience.
TOTAL HOURS SUBMITTED ON THIS AFFIDAVIT
Intern Signature
Date
Sworn to and subscribed before me, a Notary Public, this
day of
20
.
My commission expires
Notary Public
Notary Seal
Notary Stamp
Page 18
Revised 6/2003
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