| Application - PHARMACY INTERN | |
|---|---|
| Name | ROXANNE RODRIGUEZ-SOLARES |
| Credential | PHARMACY INTERN |
| Fee Details | |
| Initial Registration Fee | $60.00 |
| $60.00 | |
| Before You Begin | |||||||||||||||||
| As part of this application process you will need to get the School Certification Form and have your school representative complete it. Then you will have to scan and then upload the signed form as part of this application. | |||||||||||||||||
| Online Application Start Instructions | |||||||||||||||||
| Please Note: THIS APPLICATION SHOULD NOT BE USED TO RENEW OR REINSTATE A CREDENTIAL. Please email dcp.online@ct.gov to request your User ID and Password to renew. |
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| PAYMENT INSTRUCTIONS -To continue processing your application, please click "Next" below (read the rest of this information first).
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| Application Confirmation | |||||||||||||||||
What You Should Know Before You Begin:
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| 1. Do you understand and agree to these terms and wish to proceed with this application? | |||||||||||||||||
| Yes |
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| New Application Individual Information | |||||||||||||||||
| 2. Provide your date of birth | |||||||||||||||||
| 02/19/1989 |
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| 3. Select gender | |||||||||||||||||
| Female |
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| 4. Are you a United States citizen? | |||||||||||||||||
| Yes |
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| Social Security # | |||||||||||||||||
| The Federal Privacy Act of 1974 requires that you be notified that disclosure of your Social Security Number is required pursuant to C.G.S. ยง17b-137a. If you choose not to disclose your Social Security Number your application cannot be processed. |
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| 5. Social Security Number: (no dashes) | |||||||||||||||||
| ********** | |||||||||||||||||
| Supervising Pharmacy and Pharmacist | |||||||||||||||||
| 6.
Click ADD to search for your Pharmacist Manager or Director of Pharmacy. Enter "PHARMACIST" under "License Type" and then enter name. After completing the pharmacist selection select ADD again. Enter "PHARMACy" under "License Type" and then enter the name of the pharmacy. |
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| School of Pharmacy | |||||||||||||||||
| 7. Indicate the School or College of Pharmacy you are currently enrolled in along with the address. | |||||||||||||||||
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| 8. Have the Dean/Registrar of the School or College of Pharmacy or their designated representative complete theSchool Certification Form. Upon the completion of this form return to the online application and upload the form. | |||||||||||||||||
| school certification form wne 2023.pdf |
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| Attestation | |||||||||||||||||
| 9. Under penalty of false statement, a class A misdemeanor, I attest that the information provided in this application is the truth to the best of my knowledge. | |||||||||||||||||
| Yes |
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| Review | |||||||||||||||||