Application for. Pharmacy Technician

Transcription

1 Application for Pharmacy Technician

2 Cumberland Salem Workforce Education Alliance Certified Pharmacy Technician Do you have good customer service skills? Do you enjoy working as part of team? If you answered yes, then a career as a Pharmacy Technician could be right for you. In this job, you will interact with patients, coworkers, and health care professionals. As a Pharmacy Technician you will assist the pharmacist package or mix prescriptions, maintain client records, refer clients for counseling, assist with inventory control and purchasing, as well as collect payment and coordinate billing. Employment of pharmacy technicians is expected to increase by 32 percent over the next decade, which is much faster than the average for all occupations. Pharmacy technicians can find work in many areas from retail or mail-order pharmacies, to hospitals, clinics, and rehabilitation sites. Applicants must apply to this program and a limited number of students will be selected. Eligible applicants will have a high school diploma or equivalent, pass a basic skills math and reading test and complete a background check. A non-refundable application fee of $75 is required to apply to the program. Upon successful completion of this program you will receive a certificate of completion and prepare to take the national Pharmacy Technician Certification Board (PTCB) exam. The course fees include: externship placement, national certification exam, CPR for healthcare workers, background check and a certificate of completion.

3 Application Instructions: 1) All information given on the application form must be typed or neatly printed. 2) A check or money order for $75.00, non-refundable application fee must be enclosed 3) The completed application, and any subsequent correspondence, must be mailed to the Professional & Community Education Department, PO Box 1500, Vineland, NJ Attention: Nancy Pollard 4) Arrange for an official copy of your high school, GED and/or college transcripts to be forwarded to Professional & Community Education Department by calling or writing to your high school. Copies of high school diplomas are not acceptable. 5) Applicants are required to ask two individuals to provide letters of recommendation in support of their application. These references may not be family members. References should be responsible adults who can attest to your ability to successfully complete this training (e.g., employers, instructors, advisors, clergy or medical personnel). References are to be mailed by these individuals to the Professional & Community Education Department. 7) Applicants must submit the Immunization & Tests form along with their application, showing proof of Hepatitis B vaccination ( 3 shot series) and recent (one year or less) tuberculin test. 8) In order for the application to be considered, it must be complete.

4 Pharmacy Technician Certification Program APPLICATION Please type or print clearly and mail to: Cumberland County College, Cumberland Salem Workforce Education Alliance, PO Box 1500, Vineland, NJ Attention: Nancy Pollard Name Last First Middle Other/Previous Name (which may appear on records) Address Number & Street Apt. Number City State Zip code Phone: Home: ( ) Work: ( ) Social Security Number Date of Birth How did you hear about the Pharmacy Technician Training Program? Extra Curricular Activities (please list all school, community or religious activities in which you have participated. Include all offices which you have held and honors you have received.) Give names and address of the two persons to whom you have submitted the recommendation forms. These references must not be family members. The references should be responsible adults who can attest to your ability to successfully complete this training. Name Title/Position

5 Address Phone ( ) Relationship to Applicant Name Title/Position Address Phone ( ) Relationship to Applicant Educational Background School City Dates Attended Degree High School College Special Certification Employment History Present Employer Phone ( ) Address Dates of Employment Nature of Work Name of Employer Phone ( ) Address Dates of Employment Nature of Work

6 Statement of Interest Please explain why you wish to work in the health care industry as a Pharmacy Technician: Applicant s Name Date

7 Pharmacy Technician Certification Program Certificate of Information I certify, to the best of my knowledge, that the information supplied on this application is complete and accurate. Applicant s signature Date Cumberland County College admits students without regard for race, color, creed, sex, age, religion, national/ethnic origin, sexual orientation, disability, pregnancy or military status.

8 Pharmacy Technician Immunization & Tests Name Age Sex Address City State Zip Immunization & Test History Vaccine Dose Date Hepatitis B 1. / / 2. / / 3. / / Tuberculin Tests Arm / Device / Antigen / Manufacturer Dates Applied / / / Date Read Results (mm) Signature of Examiner Print Name of Examiner Address City State Zip Date

9 RELEASE OF INFORMATION FORM I, (print name), authorize Cumberland Salem Workforce Education Alliance to release all of my records pertaining to my criminal history, which includes my name, social security number, date of birth, address, and student ID number to IdentityPi.com. I understand that the use of my records is limited to and in connection with any audit and the evaluation of continuing education programs, and in connection with the enforcement of the federal and/or state laws. My signature is an acknowledgement that I have read and voluntarily consent to the release of the above-mentioned information. Student Signature Date Address Social Security # Phone Number *SSN is used for criminal background check purposes only cccreleaseofinformationform

10 Application Checklist check or money order and $75.00, GED and/or college transcripts forwarded to the Cumberland Salem Workforce Education Alliance Background check waiver. s of recommendation forwarded to Cumberland Salem Workforce Education Alliance Immunization records for: Hepatitis B TB screen