Page 1 BOARD OF PHARMACY NEW LICENSE APPLICATIONPlease read instructions before completing this form. If you have any questions, call HPLA Customer Service at 1-877-672-2174, Monday through Friday, 8:15 AM to 4:40 PM EST. A charge of $65.00 will be imposed for dishonored checks (Public Law 89-208) SECTION 1. REQUES TED LICENSE TYPE/FEES (non - refundable fee ) PH Pharmacist by Examination $ 280 .00 PH Pharmacist by Reciprocity $ 280 .00 PH Pharmacist by Reciprocity w/ Waiver of Licensure Transfer $ 280 .00 PH Score Transfer $ 280 .00 MPJE Jurisprudence District Re - examination / NAPLEX $ 8 5.00 PHI Pharmacy Intern U. S. Students $ 50 .00 PHI Pharmacy Foreign Students $ 50.00 VAC Vaccination and Immunization Agent $ 50.00 DC License Pharmacist - Adding VAC authority $ 50.00 DC PH license number PH Duplicate Licenses (limit 5) X $ 34 .00 = $ .00 Total Enclosed $ .00 All applicants are required to undergo a Criminal Background Check Criminal Background Check : For payment and to schedule an appointment , c all 1 - 877 - 783 - 4787 or use the following webpage: http://www.l1enrollment.com/ Make check or money order payable to DC Treasurer. MAIL TO: Department of Health Health Regulation and Licensing Administration Board of Pharmacy P.O. Box 37803 Washington, DC 200 13 HPLA ONLY Check $ Check # Staff $ .00 SECTION 2. APPLICANT NAME/DEMOGRAPHIC INFORMATION Enter your name exactly as it should appear on the license. If your name has changed at any point since you first attended c ollege or university, please complete Section 4 on page 2. You must also provide a copy of a legal name change document for EACH t ime that it has changed. Acceptable documents for individuals are marriage certificates, divorce decrees, or court orders. FIRST NAME MI LAST NAME SUFFIX (Jr., Sr., etc.) MM DD YYYY SOCIAL SECURITY NUMBER If applicant does not provide a social security number, a sworn affidavit is required. DATE OF BIRTH Male Female PLACE OF BIRTH Provide City and State for US birthplace or Country for foreign place of birth. GENDER Please check the correct box. SECTION 3. SUPPORTING DOCUMENTS REQUIRED Please indicate the supporting documents you have included with this package or requested to be sent to the Board of Pharmacy. Keep a photocopy of all supporting documents for your records. HPLA ONLY A. Two recent and identical passport - on the back. The photos must be original photos and cannot be computer - generated copies or paper copies. RE - EXAM APPLICANTS ARE NOT REQUIRED TO SUBMIT PHOTOS. YES NO B. If applying by Examination: Official transcript (with seal) showing successful completion of an educational program in the practice of pharmacy and holds a Bachelor of Science or Doctorate of Pharmacy degree from a School of Pharmacy accredited by the Amer ican Council of Pharmaceutical Education (ACPE). May be sent directly from the school, but is preferred that it accompany the application in a sealed envelope. IPP I /APP I Hours (1,500) and I ndependent Hours (400) are also required. YES NO C. Applicants taking the North American Pharmacist Licensing Examination (NAPLEX) or Multistate Pharmacy Jurisprudence Examination (MPJE) exam need to submit their information directly to National Associations of Boards of Pharmacy (NABP) with the appropriate exam fees. YES NO D. Foreign applicant applying for Internship must submit Foreign Pharmacist Graduate Examination Certificate. YES NO E. Score Transfer applicants must have requested to have their score transfer sent directly to the District of Columbia at the time they applied to sit for the NAPLEX and must have results sent directly to the District of Columbia Board of Pharmacy. YES NO American LegalNet, Inc. www.FormsWorkFlow.com GOVERNMENT OF THE DISTRICT OF COLUMBIA DC HEALTH HEALTH PROFESSIONAL LICENSING ADMINISTRATION NEW LICENSE APPLICATION Page 2 Revised 02/2018 F. Reciprocity Applicants: Licensure transfer report must have been requested from the National Associations of Boards of Pharmacy (NABP). YES NO G. Reciprocity by Waiver of Licensure Transfer Applicants: Provide current verification of licensure from another state Board of Pharmacy. YES NO H. If applying for or adding a VAC authority , you must provide proof of a successful completion of a ACPE certification course ap proved by the Board of Pharmacy and provide an copy of CPR Certification for Healthcare Professional s. YES NO I. As of January 3, 2011, each new applicant for licensure, registration or certification shall obtain a criminal background check. YES NO J. Are you a Pharmacy intern registering for the sole purpose of completing an IPPE or APPE? If so, y ou are not required to provide documentation of a preceptor or to notify the Board when the pharmacy intern changes preceptors or worksites. YES NO K. Preceptor Form required for any pharmacy intern working in a District of Columbia pharmacy outside of the structured program of an IPPE or APPE YES NO Section 4. PREVIOUS NAMES If your name has changed at any point since you first attended college or university, you must provide a copy of a legal name change document for EACH time that it has changed. Acceptable documents for individuals are marriage certificates, divorce decree s, or court orders. Changed to current name by: Marriage Divorce Court Order Spouse Death Certificate FIRST NAME MI LAST NAME SUFFIX Changed to current name by: Marriage Divorce Court Order Spouse Death Certificate (Jr, Sr, etc.) FIRST NAME MI LAST NAME SUFFIX Changed to current name by: Marriage Divorce Court Order Spouse Death Certificate (Jr, Sr, etc.) FIRST NAME MI LAST NAME SUFFIX Changed to current name by: Marriage Divorce Court Order Spouse Death Certificate (Jr, Sr, etc.) FIRST NAME MI LAST NAME SUFFIX (Jr, Sr, etc.) Section 5A. HOME ADDRESS Even if you have a PO Box, a street address should also be provided, if applicable. APARTMENT SUITE FLOOR PO BOX NUMBER HOME STREET ADDRESS 1 (If applicable, use this line for additional building information. Otherwise, use this line to indicat e STREET NUMBER and STREET NAME) HOME STREET ADDRESS 2 (If additional space is needed, use this line to indicate STREET NUMBER and STREET NAME) CITY STATE ZIP CODE + 4 HOME PHONE NUMBER HOME FAX NUMBER EMAIL ADDRESS Section 5B. BUSINESS ADDRESS Please note: This information will be made available to the public . COMPANY NAME APARTMENT SUITE FLOOR PO BOX NUMBER BUSINESS STREET ADDRESS 1 (If applicable, use this line for additional building information. Otherwise use this line to indi cate STREET NUMBER and STREET NAME) BUSINESS STREET ADDRESS 2 (If additional space is needed, use this line to indicate STREET NUMBER and STREET NAME) CITY STATE ZIP CODE BUSINESS PHONE NUMBER BUSINESS FAX NUMBER American LegalNet, Inc. www.FormsWorkFlow.com GOVERNMENT OF THE DISTRICT OF COLUMBIA DC HEALTH HEALTH PROFESSIONAL LICENSING ADMINISTRATION NEW LICENSE APPLICATION Page 3 Revised 02/2018 Se \ ction 5C. PREFERRED MAILING ADDRESS e licensing documents will be mailed. HOME BUSINESS Section 6A. PROFESSIONAL SCHOOLS ATTENDED List all schools that you have attended, in reverse chronological order, beginning with the most recent at the top. School Name, City, State, Country Number of Hours Completed Date of Graduation Type of Degree/Certificate Section 6B. POSTGRADUATE WORK EXPERIENCE List all work experience since graduation from college, university and professional school, in reverse chronological order, b eginning with the most recent. Organization/Institution Location Start Date End Date Type of Position (Use Key Below)* Full Time Part Time * TYPE OF POSITION KEY A. Employment B. Private Practice C. Clinical Rotation D. Instructor E. Internship F. Other (specify on separate sheet of paper) Section 6C. PROFESSIONAL LICENSES IN OTHER STATES/JURISDICTIONS List all states and jurisdictions in which you have ever held a license. Provide letters of verification from original and c urrent jurisdictions (if different). Jurisdiction Date License Was First Obtained License Number American LegalNet, Inc. www.FormsWorkFlow.com GOVERNMENT OF THE DISTRICT OF COLUMBIA DC HEALTH HEALTH PROFESSIONAL LICENSING ADMINISTRATION NEW LICENSE APPLICATION Page 4