Arizona State Board of Pharmacy

Application for Pharmacy Technician Licensure

Instructions

Instructions

Pharmacy Technician applicants must submit :
  1. $82.00 License application fee (this fee is nonrefundable)
  2. Proof of legal residency and birth date.
  3. Government-issued photo ID.
  4. Proof of high school graduation or its equivalent.
  5. Proof of passing the PTCB or ExCPT exam.
  6. A verification of licensure or certification, if applicable.
  7. A copy of a valid Arizona fingerprint clearance card.
  8. Documentation of any name changes.
  9. Court documentation, if applicable.
  10. Disciplinary orders, if applicable.
  11. License denial orders, if applicable.

Click here to read the application requirements.

Applicant Information

Provide your legal name in the spaces below
First Name
Middle Name
Last Name
Suffix

Residential Address

Address

Suite/Apt.# (Please use appropriate prefix (Example: Suite 101, Apt. 101, #101, etc.))

Zip Code
City
State
County
Mailing Address

Address

Suite/Apt.# (Please use appropriate prefix (Example: Suite 101, Apt. 101, #101, etc.))

Zip Code
City
State
County


Phone
Email
SSN (Pursuant to A.R.S. § 25-320)
Date of Birth
Have you ever been known by any other name?
Have you ever been licensed or certified to practice any profession or occupation in this state or any other state?
Are you currently employed in a pharmacy?

Regulatory Questions

Has any formal disciplinary action, including but not limited to, censure, fine, suspension, probation, restriction of practice or revocation, ever been taken against any license or professional certificate you hold or have held? If yes, provide full details, which must include the nature and date of each action and the state or jurisdiction involved. You must also provide a copy of the Order relating to each disciplinary action.
Do you have any disciplinary actions, sanctions or investigations pending against a professional license or certificate? If yes, provide full details.
Have you ever been refused or denied a license or certificate or renewal thereof to practice as a pharmacy technician, pharmacy technician trainee or any other profession in any state, territory, district or country? If yes, provide full details, which must include the type and date of application and the state or jurisdiction involved. You must also provide a copy of the Order or letter of denial.
Have you been arrested for, charged with, pled guilty or no contest to, or been convicted of two or more felony or misdemeanor offenses? If yes, provide full details, which must include the dates, courts and case numbers, states of prosecution and nature of the charges for each incident. You must also provide copies of the court documentation related to each case.
Have you been arrested for, charged with, pled guilty or no contest to, or been convicted of a single (just one) misdemeanor offense? You are not required to disclose a misdemeanor charge that was dismissed, expunged or set aside more than five years or a misdemeanor that occurred more than ten years before the date of this application, if it was your only charge. If yes, provide full details, which must include the date, court and case number, state of prosecution and nature of the charge. You must also provide copies of the court documentation related to the case.
Have you been arrested for, charged with, pled guilty or no contest to, or been convicted of a single (just one) felony offense? You are not required to disclose a felony conviction that was reduced to a misdemeanor conviction or that was dismissed, expunged or set aside more than ten years before the date of application if it was your only charge. If yes, provide full details, which must include the date, court and case number, state of prosecution and nature of the charge. You must also provide copies of the court documentation related to the case.
Confidential question: Do you currently use or are you addicted to alcohol or a controlled substance, prescription-only drug, or dangerous drug or narcotic to such an extent that your ability to safely practice as a pharmacy technician is impaired? If yes, please provide a detailed description of your use or addiction, including treatment received (dates, names of programs, names of treating physicians).
Confidential question: Do you currently suffer from a physical, mental, emotional, or nervous disorder or condition that impairs your ability to practice safely as a pharmacy technician? If yes, please provide additional information, including a detailed description of the disorder or condition and the name and contact information for all current treatment providers and for all monitoring or support programs in which you are currently participating.

Arizona Statement of Citizenship and Alien Status for Public Benefits

Title IV of the federal Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (the "Act"), 8 U.S.C. § 1621, provides that, with certain exceptions, only United States citizens, United States non-citizen nationals, non-exempt "qualified aliens" (and sometimes only particular categories of qualified aliens), nonimmigrants, and certain aliens paroled into the United States are eligible to receive state, or local public benefits. With certain exceptions, a professional license and commercial license issued by a State agency is a State public benefit.

Arizona Revised Statutes § 41-1080 requires, in general, that a person applying for a license must submit documentation to the license agency that satisfactorily demonstrates the applicant’s presence in the United States is authorized under federal law. Please see the technician instructions (proof of legal residency) for the list of acceptable documentation.

Citizenship or National Status Declaration

Are you a citizen or national of the United States?

Attachments

Proof of legal residency and birth date
Government-issued photo ID
Proof of high school graduation or its equivalent
Proof of passing the PTCB or ExCPT exam
A verification of licensure or certification, if applicable
Copy of valid Arizona fingerprint clearance card
Court documentation, if applicable
Disciplinary orders, if applicable
License denial orders, if applicable

Review Your Information

Affirm And Submit

Declarations

a. I hereby give my permission for the Arizona State Board of Pharmacy to secure additional information concerning me or any of the statements in this application from any person or any source the Board may desire.
b. I further agree to submit to questioning by the Board or any member thereof, and to substantiate my statements if desired by the Board.
c. I will notify the Board in writing within 10 working days if charged with a misdemeanor or felony involving conduct that is in violation of A.R.S. § 32-1901.01 (Unethical and Unprofessional Conduct).
d. I have included the required fee for this technician license. I understand this fee is non-refundable.
e. I intend to practice my profession in pharmacy in keeping with the spirit and the letter of the Pharmacy Act of Arizona and all the laws and rules enacted henceforth.
f. I certify that I have read and answered all the questions on this application.



Please be advised of the following pursuant to Arizona Revised Statutes (A.R.S.) § 41-1030:


A.R.S. § 41-1030 (B)

An agency shall not base a licensing decision in whole or in part on a licensing requirement or condition that is not specifically authorized by statute, rule or state tribal gaming compact. A general grant of authority in statute does not constitute a basis for imposing a licensing requirement or condition unless a rule is made pursuant to that general grant of authority that specifically authorizes the requirement or condition.

A.R.S. § 41-1030 (D)

This section may be enforced in a private civil action and relief may be awarded against the state. The court may award reasonable attorney fees, damages and all fees associated with the license application to a party that prevails in an action against the state for a violation of this section.

A.R.S. § 41-1030 (E)

A state employee may not intentionally or knowingly violate this section. A violation of this section is cause for disciplinary action or dismissal pursuant to the Agency's adopted personnel policy.

A.R.S. § 41-1030 (F)

This section does not abrogate the immunity provided by section 12-820.01 or 12-820.02.

Pursuant to section 41-1093.01, Arizona Revised Statutes, an agency shall limit all occupational regulations to regulations that are demonstrated to be necessary to specifically fulfill a public health, safety or welfare concern. Pursuant to sections 41-1093.02 and 41-1093.03, Arizona Revised Statutes, you have the right to petition this agency to repeal or modify the occupational regulation or bring an action in a court of general jurisdiction to challenge the occupational regulation and to ensure compliance with section 41-1093.01, Arizona Revised Statutes.

Please note that after you click the Submit button, you cannot make changes to your application.

Mailing Address: P.O. Box 18520, Phoenix, AZ 85005 Phone: (602) 771-2727

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