Signature: Date: 7. STATE CRIMINAL HISTORY RECORDS CHECK I affirm that I submitted a request for a State Criminal History YES NO Records Check on: Applicant’s Name: Applicant’s Signature: Date: 8. LIST OF DESIGNEES If applicable, list the names of person and/or entity that you authorize the Board to release information about your application: Name of Organization Name of Person Title 9. APPLICATION CHECKLIST Application Fee YES NO ☐ ☐ Recent Photograph YES NO ☐ ☐ Proof of National Certification (if applicable) YES NO ☐ ☐ YES NO of Passing Board-Approved Examination (if applicable) ☐ ☐ Proof of State Registration and Good Standing (if applicable) YES NO ☐ ☐ Pharmacy Technician Work Experience Affidavit (if applicable) YES NO ☐ ☐ Birth Certificate or Other Proof of Birth Date YES NO ☐ ☐ CJIS Report or Proof of CJIS Report Request YES NO ☐ ☐ Would you like to receive license renewal notification via email? YES NO ☐ ☐ Would you like to be an emergency preparedness volunteer? YES NO ☐ ☐ I, _________________________________, do solemnly or affirm under the penalties of perjury that I have personally completed this application, that the foregoing information is true, correct and complete to the best of my knowledge and belief, and that I understand that any misrepresentation may constitute grounds for revoking this registration. Applicant’s Signature: Date:
Signature: Date: 7. STATE CRIMINAL HISTORY RECORDS CHECK I affirm that I submitted a request for a State Criminal History Records Check on: YES NO Applicant’s Name: Applicant’s Signature: Date: 8. LIST OF DESIGNEES If applicable, list the names of person and/or entity that you authorize the Board to release information about your application: Name of Organization Name of Person Title 9. APPLICATION CHECKLIST Application Fee ☐ YES ☐ NO Recent Photograph ☐ YES ☐ NO Proof of National Certification (if applicable) ☐ YES ☐ NO of Passing Board-Approved Examination (if applicable) ☐ YES ☐ NO Proof of State Registration and Good Standing (if applicable) ☐ YES ☐ NO Pharmacy Technician Work Experience Affidavit (if applicable) ☐ YES ☐ NO Birth Certificate or Other Proof of Birth Date ☐ YES ☐ NO CJIS Report or Proof of CJIS Report Request ☐ YES ☐ NO Would you like to receive license renewal notification via email? ☐ YES ☐ NO Would you like to be an emergency preparedness volunteer? ☐ YES ☐ NO I, _________________________________, do solemnly or affirm under the penalties of perjury that I have personally completed this application, that the foregoing information is true, correct and complete to the best of my knowledge and belief, and that I understand that any misrepresentation may constitute grounds for revoking this registration. Applicant’s Signature: Date:
Technician_Initial_Application%2002.8.2018%20(4)%20(1).docx