:: Initial Applications ::

Instructions Step 1 / 6

The pharmacy technician trainee registration is intended for individuals who have not yet passed the PTCB or ExCPT examination and who have never before held a technician trainee or technician license with this Board. If you held a technician license with this Board in the past, you will need to renew your technician license. Please contact the Board office for information about renewing your technician license.

To qualify for registration as a technician trainee, an applicant must:

1. Be at least 18 years of age.
2. Submit an application for Pharmacy Technician Trainee Registration.
3. Demonstrate lawful presence in the United States.

All technician trainee applicants must submit :

A completed Application for Pharmacy Technician Trainee Registration and $25.00 application fee. Application fees are NON-REFUNDABLE.

Proof of legal residency and birth date. Provide a copy of one (1) of the following:

Arizona driver’s license issued after 1996 or an Arizona non-operating identification license.
Driver’s license issued by a state that verifies lawful presence in the United States.
Birth certificate or delayed birth certificate issued in any state, territory or possession of the United States.
United States certificate of birth abroad.
United States passport. ***Passport must be signed***
Foreign passport with a United States visa.
I-94 form with a photograph.
United States citizenship and immigration services employment authorization document or refugee travel document.
United States certificate of naturalization.
United States certificate of citizenship.
Tribal certificate of Indian blood.
Tribal or Bureau of Indian Affairs affidavit of birth.
Any other license that is issued by the federal government, any other state government, an agency of this state or a political subdivision of this state that requires proof of citizenship or lawful alien status before issuing the license.

NOTE: If your birth date does not appear on the document you provide to prove your legal residency, you are required to submit an additional document to prove you meet the age requirement.

Government Issued Photo ID. If the document you submit to prove your legal residency does not contain a photograph, you must also provide a government issued document that contains your photograph. Provide a copy of one (1) of the following:

Driver’s license
State ID
Passport or Passport Card

Documentation of any name changes. Please provide a copy of one (1) of the following acceptable documents:

Marriage License
Divorce Decree (showing restoration of previous name)
Court Order

Only complete applications, with copies of all required documentation and application fees, are accepted at the Board office. Please note that Board staff will not make copies for you.

Applicant Information Step 2 / 6

Provide your legal name in the space below.

First Name

Middle Name

Last Name

Alias

Physical Residential Address

Address1

Address2

Unit/Apt. No

City

State

Zip

County

Mailing Address

Check if mailing address is the same as above.

Mailing Address1

Mailing Address2

Unit/Apt. No

Mailing City

Mailing State

Mailing Zip

Mailing County

Phone Number

Email Address

Social Security Number

Date of Birth

Gender

Male

Female

*Have you ever been known by any other name?

Yes

Required Documents Step 4 / 6

Proof of legal residency and birth date

Government-issued photo ID (required if proof of legal residency does not contain a photograph).

Documentation of any name changes

Preview Step 5 / 6

Affirm and Submit Step 6 / 6

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 trainee registration. 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.

I state and depose that all facts, statements and answers provided in this application and its attachments are true and correct; I am not omitting any information that may be of value to this Board in determining my qualifications; and I agree that any falsification, omission, or withholding of information of facts concerning my qualifications as an applicant shall be sufficient grounds upon which to administratively close or deny my application for registration and shall serve as sufficient grounds for the revocation, cancellation, or suspension of my registration in pharmacy if it is not discovered until after issuance. A.R.S. § 32-1927.01

E-signature

Date

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

Pursuant to section 32-4302, Arizona revised statutes, a person shall be granted an occupational or professional license or certificate if the person has been licensed or certified in another state for at least twelve months, the license or certificate is in the same discipline and at the same practice level as the license or certificate for which the person is applying in this state and the person meets other conditions prescribed by section 32-4302, Arizona revised statutes.

Pharmacy Technician Trainee Registration Application