Authorization For Interstate Exchange Of Examination And Licensure Information Form

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ALASKA BOARD OF PHARMACY
AUTHORIZATION FOR INTERSTATE EXCHANGE OF EXAMINATION
AND LICENSURE INFORMATION
This form is essential to the application you are filing with this board. Before your application can be considered for approval, the
information requested below must be officially verified by the pharmacy board(s) in all states of licensure. Please complete the information
requested and forward it to the state(s) in which you hold or have held a license to practice. You are advised to check with that state before
forwarding this form to determine if there are additional requirements to be met before the information will be released, or if there is a
verification fee required.
PART I
TO BE COMPLETED BY THE APPLICANT (Please type or print legibly):
Last Name
First Name
Middle Name
Maiden Name
Mailing Address
City
State
Zip Code
Date of Birth
License No.
I hereby request and authorize the State of
to provide any and all pertinent information
requested in this form to the Alaska Board of Pharmacy to complete an application filed with that agency.
Signature
Date Signed
PART II - NOT TO BE COMPLETED BY THE APPLICANT
The above applicant is applying for licensure in this state. Please complete the following and return directly to the Alaska State Board
of Pharmacy.
State of
Name of Licensee
Graduate of
License No.
Issued Effective
By reciprocity/endorsement
By examination
License is current
lapsed
Expiration date
If the applicant's license has lapsed or expired, please explain why (e.g., failure to pay licensing renewal fees, etc.):
Date of NAPLEX exam
Date of other exam:
Has the applicant's license ever been suspended or revoked?
If so, for what reason?
(Please provide a copy of the suspension or revocation order,)
08-4032e (Rev. 7/00)
CONTINUED ON REVERSE SIDE

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