APPLICATION FOR ADMISSION PHARMACY TECHNICIAN PROGRAM DIXIE APPLIED TECHNOLOGY COLLEGE

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1 APPLICATION FOR ADMISSION PHARMACY TECHNICIAN PROGRAM DIXIE APPLIED TECHNOLOGY COLLEGE You must apply for formal admission to the Pharmacy Technician Program at the Dixie Applied Technology College (DXATC). Please complete all of the items in this application. Return the completed application along with the other required admission documents to the DXATC office. 1. Print Full Name: Last First Middle Initial 2. Date of Birth: 3. Cell Phone: Home Phone: 4. Mailing Address: Number and Street City State Zip Code 5. Emergency Contact: Name Relationship Number and Street City State Zip Code Telephone # You will be contacted regarding the status of your application by . Upon acceptance to the Pharmacy Technician Program, you will be issued an XMAIL.DXATC.EDU . This will be the that will be used to distribute important information. It will be your responsibility to check your on a regular basis. DXATC will not be responsible for students missing important information delivered through Address 1

2 7. Please provide information concerning high school, college, university, technical school, or other schools attended including health care training. Please also list any school you are currently attending. SCHOOL CITY AND STATE DATE OF ENTRANCE DATE OF EXIT DEGREE OR CERTIFICATION RECEIVED 8. If you have any paid health care employment experience, provide the following information. Do NOT include volunteer experience or experience that was part of a health care educational program. Start with your most recent position. EMPLOYER CITY AND STATE FULL TIME PART TIME POSITION HELD If you have had NO paid health care employment, but have observed or volunteered in a health care facility, or have been enrolled in a health care educational system, provide the following information. A. Name of facility: B. Location of facility: C. Total hours and dates of observation / volunteering / education: Hours: Dates: 2

3 9. Please provide information about other non-health related employment you may have had. Start with the most recent. EMPLOYER TYPE OF WORK FULL TIME PART TIME POSITION HELD 10. Satisfactory progress during Pharmacy Technician training requires regular attendance. As with any employer, the expectation is 100% attendance as outlined. Student must maintain a minimum of 80% attendance as outlined. In addition, the externship hours may include evenings, nights and weekends. Can you commit to follow the prescribed hours and course study required for Pharmacy Technician training? YES NO 11. List below any extracurricular activities, awards, honors, scholarships, student government, etc. 12. The ability to communicate clearly both verbally and in writing is an essential skill for all health care professionals. Please provide on an attached piece of paper, a written statement of Why I Want to be a Pharmacy Technician. Include the following information: (1) your reasons for selecting Pharmacy Technician as a career, (2) things you have accomplished that have given you the greatest satisfaction, (3) any special reasons for desiring to enter this school, and (4) your plans and aspirations for the future. Please attach to the back of the application. 13. Please provide two letters of recommendation from individuals who are familiar with your character, work ethic, etc. 14. Prior to being considered for acceptance into the Pharmacy Technician Program at DXATC, every student is fingerprinted, and a background check is conducted by the Federal Bureau of Criminal Investigation. Acceptance into the Pharmacy Technician Program is conditional upon passing the background check. Conviction of a felony, misdemeanor A or misdemeanor B may prevent you from becoming employed as a Pharmacy Technician. Individuals found guilty of a felony or misdemeanor A or B must disclose this information and submit court documents to the Pharmacy Technician Certification Board for review to determine eligibility to sit for the Pharmacy Technician Certification Exam. 3

4 If the information in this application conflicts with the results of the background check, you will automatically be released from the DXATC Pharmacy Technician Program. Utah State Law 58-17b-307 states, If convicted of one or more felonies, an applicant must receive an absolute discharge from the sentence for all felony convictions five or more years prior to the date of filing an application for licensure under this chapter. Have you ever been convicted of a felony, misdemeanor A or misdemeanor B or pled guilty to a felony, misdemeanor A or misdemeanor B? YES NO If yes, please explain: 15. If at any time while I am in the Pharmacy Technician Program I am charged/convicted with any of the above, I agree to inform DXATC Pharmacy Technician instructors. YES NO 16. Optional For statistical purposes only. Ethnic Background: Black Non-Hispanic Asian or Pacific Island Hispanic White Non-Hispanic (Caucasian) Other Gender: Female Male I do hereby certify that the statements in this application are true and complete to the best of my knowledge. I understand that falsifying information on this application may be grounds for denial of admission or dismissal from the Pharmacy Technician Program and could result in dismissal from DXATC. If I voluntarily drop or are dismissed from the Pharmacy Technician Program, I understand that admission fees, tuition and other fees paid are non-refundable. Signature: Date: 4

5 Have you included the following items? If not, your application is incomplete: Complete DXATC Adult Application Form (online or in Student Services) Pay $40 DXATC Application Fee (online or in Student Services) Pay $15 for College Placement Test (CPT) or provide documentation of CPT or ACT current within 2 years showing required scores Take the CPT if necessary (Thursday- 3 pm at DXATC) Complete Application for Financial Aid if applicable (fafsa.ed.gov) DXATC school code is make appointment to meet with Financial Aid ( ) Pay for drug screening ($20) and background ($55) Make appointment and complete drug screening & background check with Security Office ( ) Submit Pharmacy Technician Application with all necessary paperwork completed including: Completed Application with all signatures Personal Letter (Why I Want to be a Pharmacy Technician) Photo Two letters of recommendation CPT/ACT results with required scores or H.S./College Transcripts Receipt from fingerprinting/background check Receipt from drug screening Proof of completed/in-process immunizations Completed Health Assessment Completed PhT Interview form Signed Background Screening Student Information Signed Mental & Physical Job Requirements Signed Minor Consent For (if applicable) Signed Release of Information Authorization (FERPA) For more information call or Dixie Applied Technology College or

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