Form 12567 - Application For Pharmacist Intern Registration

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APPLICATION FOR PHARMACIST INTERN REGISTRATION
INDIANA BOARD OF PHARMACY
PROFESSIONAL LICENSING AGENCY
State Form 12567 (R9 / 4-07)
402 West Washington Street, Room W072
Approved by State Board of Accounts, 2007
Indianapolis, Indiana 46204
Telephone: (317) 234-2067
Fax: (317) 233-5559
E-mail: pla4@pla.IN.gov
INSTRUCTIONS: Please type or print legibly.
MANDATORY DISCLOSURE OF U.S. SOCIAL SECURITY NUMBER
*
Pursuant to Section 7 of the Privacy Act of 1974, you are hereby given notice that disclosure of your U.S. Social Security number on your application is
mandatory for the purpose of complying with IC 25-1-5-8 and IC 4-1-8-1 which provide that the Indiana Department of Revenue may obtain your Social
Security number from the Professional Licensing Agency for tax enforcement purposes. In addition, disclosing such number is mandatory in order for the
licensing board or committee to comply with the requirements of the federal National Practitioner Data Bank and the Healthcare Integrity and Protection Data
Bank 42 U.S.C. § 1320(a)-7e(b), 5 U.S.C. § 552a, 45 CFR Part 60.1, and 45 CFR Part 61.
Failure to disclose your U.S. Social Security number will result in the denial of your application. Application fees are not refundable.
FOR OFFICE USE ONLY
APPLICATION FEE
DATE FEE PAID (month, day, year)
One (1) photograph required.
Recent head and shoulder 2” X 2”
DATE OF ISSUANCE (month, day, year)
photo must be attached to
application. Photo must be of
REGISTRATION NUMBER
passport quality.
RECEIPT NUMBER
CM
DO NOT WRITE ABOVE THIS LINE
INFORMATION ABOUT THE APPLICANT
Name of applicant (last, first, middle)
Maiden name of applicant (if applicable)
Address (number and street, city, state, and ZIP code)
*
Date of birth (month, day, year)
Place of birth (city, state)
Social Security number
Telephone number
E-mail address
(
)
Are you enrolled in a
If “Yes”, where?
If “No”, do you plan to enroll in or
If “Yes”, when and where?
college of pharmacy?
are you a graduate of a college
of pharmacy?
Yes
No
Yes
No
If your answer is “Yes” to any of the following, explain fully in a signed and notarized statement, including all related details and documentation.
Include violation, location, date and disposition. Falsification of any of the following is grounds for permanent revocation of a registration
issued pursuant to this application.
1. Has disciplinary action ever been taken regarding any health license, certificate, or registration you hold or
Yes
No
have held in any state or country?
2. Have you ever been denied a license, certificate, registration, or permit to practice as a pharmacist intern
Yes
No
or any regulated health occupation in any state or country?
3. Are there any charges pending against you regarding a violation of any Federal, State or Local law relating
Yes
No
to the use, manufacturing, distribution or dispensing of controlled substances, alcohol, or other drugs?
4. Have you ever been convicted or pled guilty or nolo contendre to:
Yes
No
i. A violation of any Federal, State, or Local law relating to the use, manufacturing, distribution, or
dispensing of controlled substance, alcohol, or other drugs?
ii. To any offense, misdemeanor or felony in any state (except for minor violations of traffic laws resulting
Yes
No
in fines?)
5. Have you ever been treated for drug or alcohol abuse?
Yes
No

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