Fillable Form 12567 - Application For Intern/extern License (Page 2 of 2) in pdf

An applicant for registration as a pharmacist intern or pharmacist extern must furnish satisfactory proof to the Board, that he or she is

enrolled in a pre-pharmacy or pharmacy curriculum at an accredited school of pharmacy. The period of experience shall be computed

from the date of registration as a pharmacist intern and any such person who fails or refuses to register as a pharmacist intern shall receive

no credit for experience as an employee in a pharmacy. This certificate as an intern shall be valid for a period of six (6) years from its

issuance date and may be renewed for an additional period of five (5) years for good cause shown.

To become a Pharmacist, the applicant, prior to the examination, shall produce and file such evidence as is satisfactory to the Board of

having served as a registered pharmacist intern according to the laws and regulations governing intern /extern time. The Board shall

establish standards regarding the minimum period of time acquired by a registered apprentice and shall give due consideration to such

factors as the number of hours served per week, the number of hours actually spent in a Pharmacy where physician’s prescriptions are

compounded, and the number of hours spent as apprentice prior to or after graduation from a School of Pharmacy. All such standards

established by the Board shall be in the form of a duly promulgated rule or regulation, and said rule or regulation may be changed as

the Board, in its discretion, determines necessary based upon the need for training and experience in the field of pharmacy.

Credits for practical experience may not be counted for any work period less than four (4) hours per week or more than sixty (60) hours

per week.

The summarization of accredited experience time as indicated on a preceptor’s report filed with Executive Director of the Board of Pharmacy

after the termination of employment will constitute the formal record of intern /extern time as required by law. Failure of a Preceptor to

file such a report invalidates crediting of such intern / extern time.

Any person submitting an application for a certificate as a pharmacist intern / extern may be required to undergo an examination for the

purpose of ascertaining education qualifications.

Foreign pharmacists may submit proof of their Foreign Pharmacist Graduate Examination Certificate (FPGEC) or a notarized copy of their

diploma from their col lege of pharmacy in l ieu of having t he Dean com pl et e the porti on of this appl icat ion.

SPONSOR’S STATEMENT

FOR REGISTERED APPRENTICE PHARMACIST APPLICATION

To the Indiana Board of Pharmacy:

, of

County of

, State of Indiana, do hereby make the following statement for the

benefit of

who is an applicant for registration as an Apprentice Pharmacist.

Name of licensed Pharmacist (first, middle, last)

License number

Name of employing pharmacy

Pharmacy permit number

Address of pharmacy (number and street, city, state, ZIP code)

AFFIDAVIT

(Check one)

On this day, I certify that I am a licensed pharmacist holding the license number listed above in Indiana and that the above named pharmacy intern

will be in my employ, compounding and filling prescriptions for medical practitioners under my supervision at the above named pharmacy.

On this day, I certify that the applicant named herein is enrolled in a college of pharmacy and will be entering an externship program. Within the

program the applicant will be filling and compounding prescriptions under the direct supervision of a licensed pharmacist in a licensed pharmacy.

I solemnly swear, or affirm that the statements given above are true and correct to the best of my knowledge.

Signature of licensed Pharmacist

Date signed

Form 12567 - Application For Intern/extern License Page 2