Form 12567 - Application For Intern/extern License
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1
2APPLICATION FOR INTERN / EXTERN LICENSE
State Form 12567 (R7 / 10-00)
Approved by State Board of Accounts, 2001
HEALTH PROFESSIONS BUREAU
Board of Pharmacy
Recent head and shoulder
402 W. Washington St., Rm 041
2" x 2" photo must be
Indianapolis, IN 46204
attached to application
FEE $10.00
(317) 232-2960
Photos must be of
passport quality
* The request for your Social Security number is MANDATORY according to IC 4-1-8-1 and this application
cannot be processed without it.
FOR OFFICE USE ONLY
Name of applicant (last, first, middle)
Receipt number
Address (number and street, city, state, ZIP code)
Fee
Date
Certificate number
Social Security number *
Date of birth (month, day, year)
Date issued
Are you now enrolled
If "No", do you plan
If "Yes", when?
If "Yes", where?
Yes
Yes
in a College of
to enroll in a College
Pharmacy?
No
of Pharmacy?
No
Are you a graduate
If "Yes", where and when?
Yes
of a College of
Pharmacy?
No
Name and license number of Preceptor (If employed)
Place of employment (Name and full address of pharmacy)
I, _________________________________________ , above named, hereby swear or affirm under the penalties of perjury that the statements
(signature)
made by me in this application for licensure as an Apprentice Pharmacist are true and correct on this _________________________ day of
_________________________ , 20_____ .
NOTE TO APPLICANT: The certificate below is not required if previously provided to the Board.
CERTIFICATE OF ENROLLMENT OR GRADUATION IN PHARMACY EDUCATION
To be filled in and signed by the Secretary or Dean of the School or College of Pharmacy of which the applicant is enrolled / a graduate.
This is to certify that __________________________________________________________________________________ is enrolled / a graduate of
______________________________________________________________________________________________________________________
Number of years pre-pharmacy
Date
Number of years pharmacy
Name of School or College of Pharmacy
City, state
Signature of Secretary or Dean
(SEAL)
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