Pharmacy Technician Enrollment Form

To apply for admission to the Pharmacy Technician Program please complete all sections of this form.

First and Last Name

Email Address

Street Address

City, State , Zip Code

Mobil Phone

Date of Birth

Are you a Veteran?

Yes No

High School Diploma or GED?

Yes No

College?

Associate of Arts Associate of Science Bachelor's Graduate Master's

Intent/Goal

To become a retail pharmacy technician To become a certified pharmacy technician To improve present job skills To become a pharmacist

Preferred Time Of Day

Morning Afternoon Evening

Method of transportation

Driving Public transportation Uber or Lyft

Preferred Day Of The Week

Monday Tuesday Wednesday Thursday Friday Saturday

Print your name the way you would like it to appear on the "Certificate of Completion"