Pharmacy Technician Course Form

Start Date*

Last Name *

First Name *

Middle Initial

Address *

City *

State

Zip

Phone Number*

Cell

Email *

Emergency Contact Name *

Relationship

Phone Number *

Education

College

Name of High School Attended

Address

Do you have a high school Diploma or G.E.D.?

Yes

No

If NO did you complete 12th grade?

Yes

No

Please provide a copy of School Diploma or Transcript.
In absence of high school Diploma, student is required to take a placement test ( T.A.B.E. –Math computation, Applied Math and Reading.

TABE test score

List of any other educational experience