Application - PHARMACY INTERN
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.





PAYMENT INSTRUCTIONS -To continue processing your application, please click "Next" below (read the rest of this information first).


On the review screen, click "Add to Invoice."


On the top right of the invoice screen, select "Pay Invoice".


PLEASE NOTE THAT WHEN ENTERING YOUR CREDIT CARD NUMBER, DO NOT ENTER SPACES OR DASHES AS IT WILL RESULT IN A FAILED TRANSACTION.


Thank you for using the online system.

 

Application Confirmation
Stop Sign Pursuant to Public Act 18-40, all application fees are non-refundable and non-transferable.

What You Should Know Before You Begin:
  • This application should not be used to reinstate or renew an existing registration. Contact DCP.Online@ct.gov for further instructions.

  • Please be sure you are not submitting a duplicate application for a registration you already hold or one that is pending. You can verify pending applications by searching the applicant's name at www.elicense.ct.gov

  • Please be sure you have read all instructions and requirements regarding eligibility before submitting this application.

  • The fee which accompanies an application covers the cost of reviewing and processing that specific application, it cannot be refunded, even if the applicant is found ineligible.


1.  Do you understand and agree to these terms and wish to proceed with this application?
Yes
 

New Application Individual Information
2.  Provide your date of birth
02/19/1989
 
3.  Select gender
Female
 
4.  Are you a United States citizen?
Yes
 

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.

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.
Supervisor  Status  Relationship Type  Approved Date  Start Date 
PCT.0008107 : MATTISON MELISSA
Active
SUPERVISING PHARMACIST
09/02/2023
09/02/2023
 

School of Pharmacy
7.  Indicate the School or College of Pharmacy you are currently enrolled in along with the address.
School  Attendence Status  Dates Attended  Date Graduated  Degree/Specialty  Total Hours  Board Certified Date  Comments 
School Name: Western New England University
Springfield
Massachusetts
UNITED STATES
School Type: COLLEGE/ UNIVERSITY
School Name: Other
Active






 
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
 

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
 

Review