Verification Of Pharmacy Education Form - Alaska State Board Of Pharmacy printable pdf download

Verification Of Pharmacy Education Form - Alaska State Board Of Pharmacy

ALASKA STATE BOARD OF PHARMACY

VERIFICATION OF PHARMACY EDUCATION

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 college where your degree was earned and submitted with an official transcript.

Please complete the information in Section A and forward it to the college and they, in turn, will complete the remainder of this form and

return it to this agency along with your official transcript. You are advised to check with that college 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 transcript fee required.

SECTION A

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:

I hereby request and authorize

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

SECTION B – Complete for graduated students and submit with official transcript.

CERTIFICATE OF DEAN OF COLLEGE GRANTING DEGREE

I hereby certify that

matriculated in the

College on the ______ day of

, has

attended ______ hours of instruction, graduating with a

degree on the day of

Signature of Dean

SEAL OF COLLEGE OR UNIVERSITY

Date

SECTION C – Complete for pre-graduate students and submit with official transcript.

CERTIFICATE OF REGISTRAR OF COLLEGE

I hereby certify that

matriculated in the

College on the ______ day of

has

attended ______ hours of instruction, (1) is currently enrolled in the college; (2) is actively pursuing completion of a pharmacy curriculum;

and (3) has obtained senior status of a five-year or six-year pharmacy curriculum.

Expected Graduation Date:

Signature of Registrar

SEAL OR COLLEGE OR UNIVERSITY

Date

An official transcript must accompany this form.

Please return this form directly to:

Department of Community and

Economic Development

Division of Occupational Licensing

Board of Pharmacy

P.O. Box 110806

Juneau, AK 99811-0806

08-4032d (Rev. 7/00)

Verification Of Pharmacy Education Form - Alaska State Board Of Pharmacy

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