Arizona State Board of Pharmacy

Pharmacy Technician Trainee Registration Application

Instructions Step 1 / 7

Applicant Information Step 2 / 7

Are you currently employed in a pharmacy?
Have you ever been licensed or certified to practice any profession or occupation?
*Have you ever been known by any other name?
In accordance with the following statute, the board must record an Address of Record to keep on file that may be disclosed to the public.

A.R.S. §32-3226. Address of record; disclosure; telephone number or email address; definition

A. A health profession regulatory board shall have, for each licensee under the board's regulation, an address of record designated by the licensee that may be disclosed to the public. If the licensee designates the licensee's residential address as the address of record, the board shall notify the licensee of the public disclosure and allow the licensee to opt out of the disclosure.

E. For the purposes of this section, "address of record" means either:

          1. The address where a health professional practices the person's health profession or is otherwise employed.

          2. The health professional's residential address.

Regulatory Questions Step 3 / 7

1
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 (including with this Board)? 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.
2
Do you have any disciplinary actions, sanctions or investigations pending against a professional license or certificate? If yes, provide full details.
3
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 (including with this Board)? 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.
4
Have you been arrested for, charged with, pleaded 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.
5
Have you been arrested for, charged with, pleaded 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.
6
Have you been arrested for, charged with, pleaded 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.
7
Are you currently subject to another regulatory board’s order, in this or another state, relating to the monitoring of a health condition? For the purpose of this question, “health condition” includes substance use. You are not required to disclose your participation and monitoring in a confidential program. If the answer to this question is “YES” and your participation is not confidential, please provide a copy of the current order.
8
Do you currently suffer from a physical disorder or condition that impairs your ability to practice safely? 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

Citizenship Step 4 / 7

Are you a citizen or national of the United States?
(A). Qualified Alien Status(8 U.S.C.§§ 1621(a)(1),-1641(b) and (c))

Required Documents Step 5 / 7

Preview Step 6 / 7

Affirm and Submit Step 7 / 7

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

  

  

  

  

  

  
  
  
  
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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