Montana Board of Pharmacy PHARMACIST APPLICATION REVISED 06/18 Page 1 of 5 Montana Board of Pharmacy PO Box 200513 301 S Park, 4th Floor Helena, MT 59620-0512 Phone: 406-841-2300 Fax: 406-841-2305 Email: dlibsdpha@mt.gov Website: www.pharmacy.mt.gov Application for Licensure as a Registered Pharmacist: Montana Application License Transfer/Credentialing from Another State Foreign Graduate EXAMINATIONS: MPJE NAPLEX 1. FULL NAME: Last First Middle 2. OTHER NAME(S) KNOWN BY 3. BUSINESS NAME 4. BUSINESS ADDRESS Street or PO Box # City and State Zip 5. HOME ADDRESS Street or PO Box # City and State Zip PREFERRED MAILING ADDRESS Business Home E-MAIL ADDRESS 6. BUSINESS PHONE HOME PHONE FAX 7. SOCIAL SECURITY NUMBER FOREIGN ID NUMBER 8. DATE OF BIRTH FEMALE MALE 9. LICENSE NAME (State your name as it should appear on the license if granted.) Character, Endorsement, and Discipline Questions Please answer the following questions. If you answer yes, give specific details (names of organizations, dates, reasons, and outcome) on a Supplement Sheet. 10. If taking an examination, do you have any physical or mental impairment(s) requiring special accommodation(s)? If yes, attach a detailed explanation. Yes No 11. Have you ever taken the licensure examination in Montana or any other state? If yes, give state, date, and results. Yes No 12. Have you ever been denied the right to take this profession's licensing examination in any state? If yes, attach a detailed explanation. Yes No 13. Are you requesting the immunization certification endorsement on your license? If yes, attached proof of immunization certification and CPR training. Yes No AFFIX PHOTO HERE PASSPORT SIZE American LegalNet, Inc. www.FormsWorkFlow.com Montana Board of Pharmacy PHARMACIST APPLICATION REVISED 06/18 Page 2 of 5 14. List all professional licenses, registrations, or certificates you hold or ever have held. You are not required to verify a license that is verified by the NABP license transfer process e-LTP. State License # Issue Date Expiration Date Type of License 15. Ha ve you ever ha d an application for a professional or occupation license refused or denied? If yes, please attach a detailed explanation and provide supporting documentation from the source. Yes No 16 . Ha ve you ever withdrawn an application for licensure prior to the licensing agency's decision regarding your application? If yes, please attach a detailed explanation and provide supporting documentation from the source. Yes No 1 7 . Ha ve you ever been denied the privilege of taking an examination required for any professional or occupational license? If yes, please attach a detailed explanation and provide supporting documentation from the source. Yes No 1 8 . Ha ve you ever withdrawn or been suspended, placed on probation, expelled or Requested to resign from any postsecondary educational program? If yes, please Attach a detailed explanation and provide supporting documentation from the source. Yes No 1 9 . Ha ve you ever requested temporary or permanent leave of absence, been placed on probation, restricted, suspended, revoked, allowed to resign, or otherwise acted against by any professional or occupational education program (i.e., residency, internship, apprenticeship, etc.)? If yes, please attach a detailed explanation and provide supporting documentation from the source. Yes No 20. Has a licensing agency initiated or completed disciplinary action against Any professional or occupational license you have held? If yes, please provide agency documents including the complaint, initiating documents, orders, final orders, stipulations and consent and/or settlement agreements directly from the source. Yes No 21. Have you ever voluntarily surrendered, cancelled, forfeited, failed to renew a professional or occupational license in anticipation of or during an investigation or disciplinary proceeding or action? If yes, please attach a detailed explanation and provide supporting documentation from the source. Yes No 2 2 . Has a complaint ever been made against you with a professional or occupational licensing agency? If yes, please attach a detailed explanation and provide supporting documentation from the source. Yes No 23. Have you ever been the subject of any sanction or action, denial, suspension, revocation, restriction or termination regarding hospital, facility or staff privileges; health maintenance organization participation, third party provider or Medicare/Medicaid participation; or any other privileges? If yes, please attach a detailed explanation and provide supporting documentation from the source. Yes N 2 4 . Ha ve you ever been censured, expelled, denied membership or asked to resign from a professional organization related to the profession or occupation? If yes, please attach a detailed explanation and provide documentation from the source. Yes No American LegalNet, Inc. www.FormsWorkFlow.com Montana Board of Pharmacy PHARMACIST APPLICATION REVISED 06/18 Page 3 of 5 2 5 . Ha ve you ever been the subject of any sanction or action, denial, suspension, revocation, restriction or termination regarding your ability to prescribe, dispense or administer drugs including controlled substances? If yes, please attach a detailed explanation and provide documentation from the source. Yes No 2 6 . Do you have any initiated or completed action against you by any state, federal, tribal, or foreign licensing jurisdiction? (For example: Drug Enforcement Agency; Alcohol, Tobacco and Firearms; Homeland Security; Indian Health Service, etc.) If yes, please attach a detailed explanation and provide documentation from the source. Yes No 2 7 . Have any civil legal proceedings been filed ag ainst you by a (patient/client), (former patient/client) or employer/employee? If yes, attach a detailed explanation and documentation from the source including initiating document(s) and documentation of final disposition. Yes No 2 8 . Have you ever been convicted of a misdemeanor or felony crime or do you have a pending criminal charge? 223Convicted224 for the purposes of this question includes a conviction under appeal, guilty plea, no contest plea, and/or forfeiture of bond. 223A pending criminal charge224 for the purposes of this question includes a deferred imposition of sentence and/or deferred prosecution. If you answer yes, a detailed you must submit a detailed explanation on the events AND the charging documents and final judgments or orders of dismissal. You must report but may omit documentation for: (1) misdemeanor traffic violations older than 10 years ago and that resulted in fines of less than $200; and (2) convictions prior to your 18th birthday unless you were tried as an adult. Yes No 2 9 . Ha ve you ever been diagnosed with chemical dependency or another addiction, or have you participated in a chemical dependency or other addiction treatment program? If yes, please attach a detailed explanation and provide documentation regarding evaluations, diagnosis, treatment recommendations and monitoring from the source. Yes No 30 . Ha ve you ever been diagnosed with a physical condition or mental health disorder involving potential health risk to the public? If yes, please provide a detailed explanation. Yes No 3 1 . Ha ve you ever been court - martialed or discharged other than honorably from any branch of the armed service? If yes, attach a detailed explanation and documentation for the source. Yes No I authorize the release of information concerning my education, training, record, character, license history and competence to practice, by anyone who might possess such information, to the Montana Board of Pharmacy. I hereby declare under penalty of perjury the information included in my application to be true and complete to the best of my knowledge. In signing this application, I am aware that a false statement or evasive answer to any question may lead to denial of my application or subsequent revocation of licensure on ethical grounds. I have read and will abide by the current licensure statutes and rules of the State of Montana governing the profession. I will abide by the current laws and rules that govern my practice.