Get Application For Pharmacist Examination And Licensure Form 17a 1

This guide provides you with comprehensive instructions on how to complete the Application For Pharmacist Examination And Licensure Form 17a 1 online. Following these steps will ensure that your application is correctly filled out, thereby facilitating a smooth licensure process.

Follow the steps to accurately complete your application form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in your full legal name (Last Name, First Name, Middle Name). Ensure that this matches the name on your identification documents exactly.
3. Provide your mailing address, including street address, city, state, and zip code. If your residence address differs, include that information as well.
4. Enter your date of birth in the format of month/day/year and your contact numbers (home, cell, and work).
5. Disclose your U.S. Social Security Number or Individual Taxpayer Identification Number. This information is mandatory.
6. Attach a passport-style photo on the designated page. The photo must be color, glossy, and sized 2"x2", taken within 60 days of your application.
7. Select and check the applicable box for your educational qualifications. Attach the required documentation for validation.
8. Fill in how you qualify as a pharmacy technician by checking the appropriate box and submitting required verification documents.
9. Complete the Self-Query Report section by including the original sealed report from the National Practitioner Data Bank (NPDB) dated within the last 60 days.
10. Provide your fingerprinting information. California residents must use Live Scan; others may provide rolled fingerprint cards. Attach the receipt or fingerprint cards as required.
11. Review each section of the form carefully to ensure that no questions are left unanswered. Use 'N/A' where applicable.
12. Sign and date the application where indicated. Remember, only original signatures are accepted within 60 days of submission.
13. Once all sections are complete, save your changes. You can download, print, or share the completed application as needed.

Ensure all sections are completed carefully and submit your Application For Pharmacist Examination And Licensure Form 17a 1 online today.