Michigan Department of Licensing and Regulatory Affairs Bureau of Professional Licensing Board of Pharmacy PO Box Lansing, MI (517)

Transcription

1 Michigan Department of Licensing and Regulatory Affairs Bureau of Professional Licensing Board of Pharmacy PO Box Lansing, MI (517)

2 PHARMACY TECHNICIAN LICENSE APPLICATION PACKET INCLUDED IN THIS PACKET 1. Mailing Information & Content...Pages Licensure Instructions... Pages Application...Pages Verification of Employment as a Pharmacy Technician Pharmacy... Pages Printing Instructions...Page 10 2

3 Michigan Department of Licensing and Regulatory Affairs Bureau of Professional Licensing Board of Pharmacy PO Box Lansing MI (517) PHARMACY TECHNICIAN LICENSURE INSTRUCTIONS Please read application instructions carefully and answer all questions completely. Failure to do so may cause a delay in your application process. 1. Applicants must complete and submit the application for licensure with the appropriate fee, as well as arrange for supporting documents to be sent to the Board of Pharmacy. All applicants for a full, limited or temporary license must comply with instructions #2 and #3. Applicants for a full license must also comply with instruction #4. 2. Applicants for pharmacy technician licensure in Michigan are required to undergo a Criminal Background Check (CBC) and provide evidence of fingerprint processing from an authorized agency. Fingerprints must be taken using the Customer ID number and instructions provided in the Application Confirmation letter that will be sent when your license application and fee are processed. Do not have your fingerprints taken prior to receiving your Customer ID number. 3. Arrange for a verification and/or certification of your license status to be sent directly to the Michigan Board of Pharmacy from any state or province where you currently hold or have ever held a permanent license or registration. Copies of licenses are not acceptable. 4. Applicants for a full license must contact their high school to have a copy of their final high school transcripts sent directly to the Board office OR have the GED testing company send verification of passing the GED examination directly to the Board office. Applicants who graduated from high school in Michigan may also be able to use the Michigan e-transcript service to have high school transcripts electronically sent to the Michigan Board. Information about this service can be found at E-transcripts should be sent to BPLData@michigan.gov. TO APPLY FOR FULL LICENSURE BY EXAMINATION: 1. The Board must also receive passing certified pharmacy technician examination scores directly from one of the following: a. Pharmacy Technician Certification Board (PTCB), 2200 C Street, NW, Suite 101, Washington, DC , , at contact@ptcb.org (PTCB scores will be obtained from their website.) OR b. National Healthcareer Association (NHA, Overbrook Road, Leawood, KS 66221, , at info@nhanow.com c. Employer based training program. 3

4 TO APPLY FOR A LIMITED LICENSE: PHARMACY TECHNICIAN LICENSURE INSTRUCTIONS 1. You must also have your employer complete the Verification of Employment as a Pharmacy Technician Form that is part of this application packet. The completed form must be sent to the Board of Pharmacy directly from your employer. 2. The limited pharmacy technician license is only valid if you remain employed by the same pharmacy. If you are no longer employed, the limited license is not valid. If you begin employment at a different pharmacy, the limited license is not valid. TO APPLY FOR A TEMPORARY LICENSE: 1. The temporary pharmacy technician license will be issued upon receipt of the application, fee and the fingerprint/criminal background check report. 2. The temporary pharmacy technician license is issued so that the applicant may continue working while preparing to take the examination required for full licensure. The temporary license is only valid for one year and cannot be renewed. 4

5 BPL/LIC-602 (10/15) Auth. PA 368 of 1978 Michigan Department of Licensing and Regulatory Affairs Board of Pharmacy PO Box Lansing MI (517) License#: Issue Date: FOR BOARD USE ONLY APPLICATION FOR PHARMACY TECHNICIAN LICENSE Please check the box for the license type that you are apply for: Pharmacy Technician by Examination Fee: $ Pharmacy Technician-Limited Fee: $ Pharmacy Technician-Temporary Fee: $ Your check or money order drawn on a U.S. financial institution and made payable to the STATE OF MICHIGAN must accompany this application. DO NOT SEND CASH. Fees are deposited upon receipt and can only be refunded under refund rules promulgated by the Department. 1. Demographic Information First Name: Middle Name: Last Name: U.S. Social Security #: Street Address: Birth Date: Apt/Bldg#: City: State: Zip Code: Country: United States Phone Number: Address: Have you ever held a health professional license in any profession in Michigan? Was your health professional license issued after 2008? Health Professional Permanent I.D./License Number: Expiration Date: Have your ever been known under any other name? If yes, list name(s): Will documents be received under any other name? If yes, list name(s): No No No 5

6 Full Name: 2. Personal Data Questions 1. Have you ever been convicted of a felony? 2. Have you ever been convicted of a misdemeanor punishable by imprisonment for a maximum term of 2 years? 3. Have you ever been convicted of a misdemeanor involving the illegal delivery, possession, or use of alcohol or a controlled substance (including motor vehicle violations)? 4. Have you had 3 or more malpractice settlements, awards, or judgments in any consecutive 5 year period? 5. Have you had 1 or more malpractice settlements, awards or judgments totaling $200,000 in any consecutive 5 year period? 6. Have you ever been fined, denied, revoked, suspended, reprimanded, placed on probation, otherwise disciplined, or the subject of a final adverse action by a licensure, registration, disciplinary or certification board as a holder of or application for, a license or registration regulated by this state, another state or territory of the United States, the United States military, the federal government, or another country? 7. Have you ever been censured, or requested to withdraw from a health care facility s staff or had your health care staff privileges involuntarily modified? 8. Have you been treated for substance abuse in the past 2 years? Note: If you answered yes to any of the questions in Section 2 (questions 1-8), you must provide a detailed explanation with copies of all available official and/or court documents related to your explanation along with your application. If you do not provide the explanation, your application will be deemed incomplete and processing will be delayed. 6

7 Full Name: 3. Professional Education Examination Information: Identify the entity below that maintains your examination scores. Check one box only Pharmacy Technician Certification Board (PTCB) National Healthcareer Association (NHA) Provide Certification Number: Employer-Based Training Program Provide a complete chronological record of your educational preparation. Attach additional sheets if necessary. Pharmacy Technician School and Address Graduation Date: Degree Granted: 4. License(s) in Other State (s) or Province (s) Do you hold or have you held a pharmacist or pharmacy technician license or registration in any state or province? If yes, list each state or province, the license or registration number, the date issued and how the license was obtained (either examination or endorsement). (Attach additional sheets if necessary.) DO NOT LIST TEMPORARY LICENSES. State/Country Profession Permanent License/Registration Number Date of Issue Number of Years Licensed Expiration Date How Obtained (Exam or Endorsement) 5. Certification I understand that it is the policy of this agency to secure a criminal conviction history as part of the pre-licensure screening process. I authorize this agency to use the information provided in this application to obtain a criminal conviction history file search from the Central Records Division of the Michigan Department of State Police, law enforcement, or judicial record-keeping organization. I further consent to the release of information to this agency regarding any disciplinary investigations conducted by a similar licensure registration, or specialty certification board of this or any other state, of the United States military, of the federal government, or of another country. The statements in this application are true and correct. I have not withheld information that might affect the decision to be made on this application. In signing this application, I am aware that a false statement or dishonest answer may be grounds for denial of my application or revocation of my license and that such misrepresentation is punishable by law. Signature of Applicant Date The Department of Licensing and Regulatory Affairs will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status, disability or political beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency. 7

8 Michigan Department of Licensing and Regulatory Affairs Board of Pharmacy PO Box Lansing MI (517) VERIFICATION OF EMPLOYMENT AS A PHARMACY TECHNICIAN Authority: Public Act 368 of 1978, as amended. THIS FORM IS ONLY USED WHEN APPLYING FOR A LIMITED PHARMACY TECHNICIAN LICENSE. SECTION I-APPLICANT INFORMATION Instructions: Complete Section I. Type or print your name exactly as it appears on your application. For completion of Section II, send this form to your employer. This verification must be submitted directly to the Michigan Board of Pharmacy by your employer. First Name: Middle Name: Last Name: Street Address: Apt/Bldg#: City: State: Zip Code: SSN: Date of Birth: Signature of Applicant Date APPLICANT: Upon completion of Section I, print, sign, and date the form then send the form to your employer for completion of Section II. 8

9 THIS SIDE TO BE COMPLETED BY THE EMPLOYER Please complete the following information. Return this completed verification directly to the Michigan Board of Pharmacy, PO Box 30670, Lansing, MI SECTION II-VERIFICATION OF EMPLOYMENT I certify that (Applicant's Full Name) was employed on December 22, 2014, and has been satisfactorily employed as a pharmacy technician for at least 1,000 hours during the 2-year period immediately preceding the date of his/her application for a Michigan Limited Pharmacy Technician License, and is currently employed at (Name of business/agency) (Pharmacy License Number) (Street Address) (City) (State) (Zip Code) The applicant s starting date of employment was/is: The applicant s position is: The applicant is supervised by the following pharmacist: (Name of Pharmacist) (Pharmacist License Number) Signature and Title Print or Type Name Date Phone Number/ Address 9

10 Please print out the Application (pages 5-7) and the Verification of Employment as a Pharmacy Technician (if applicable, pages 8-9). Sign and date your application, and submit the application along with your check or money order made payable to the State of Michigan to: Michigan Department of Licensing and Regulatory Affairs Bureau of Professional Licensing Board of Pharmacy PO Box Lansing MI If applicable, submit the Verification of Employment as a Pharmacy Technician form to your employer to complete and send directly to our office. 10