USVI Public Records

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VIRGIN ISLANDS BOARD OF PHARMACY Department of Health P.O. Box 222995 Christiansted, VI 00822-2995 Tel: 340-718-1311 Email: BoardofPharmacy@doh.vi.gov To Whom It May Concern: Thank you for your recent request for information regarding licensure for the Practice of Pharmacy in the U.S. Virgin Islands. The Virgin Islands Board of Pharmacy is now an active member of the National Association of Boards of Pharmacy (NABP). As such, we are also a member of the Licensure Transfer Program. Since you are licensed in another state(s) you can access the NABP website at www.napb.net for the application for Licensure Transfer. Once the application has been cleared by NABP, the Board will make its final decision and inform you. You are also required to complete and submit our Pharmacy application, which is enclosed. If you have any questions, you may contact the Board at the above numbers. Thank you for your interest. Sincerely, Amy Durand, PharmD. Secretary, V.I. Board of Pharmacy Enclosure Updated February 15, 2024 Page 1 of 7 VIRGIN ISLANDS BOARD OF PHARMACY APPLICATION FOR PHARMACIST LICENSE A non-refundable application fee of $25.00 (check or money order) is required with application. NOTE ANY FALSE OR MISLEADING INFORMATION IN CONNECTION WITH THIS APPLICATION MAYBE CAUSE FOR DEBARMENT ON THE GROUND OF LACK OF GOOD MORAL CHARACTER. AFFIX e-Profile ID: ___________________ PHOTO HERE I hereby apply for licensure to practice Pharmacy in the U.S. Virgin Islands, in accordance with the terms set forth in Section 149 of Act 1714 - an Act to regulate the practice of Pharmacy in the U.S. Virgin Islands and other purposes. E-mail ________________________________ Full Name: ____________________________________________Phone: _______________________________ Mailing Address: _____________________________________________ Date of Birth: _______________________________________________ Place of Birth: _______________________________________________ Citizenship: _________________________________________________ Last 4 Digits S.S.# _______________ Father’s Name: __________________________________Mother’s Name: ______________________________ Place of expected employment on Island:__________________________________ PHARMACY COLLEGE TRAINING: I was granted a diploma of graduation from _________________________________________ on the ____ day of, ___________________the _____________________________________________degree being thereby conferred. PRACTICAL EXPERIENCE: List work experience on resume to include, begin with present or last position held: Name of agency, address of agency, position held, responsibilities, supervisor, period of employment, reason for leaving. Updated February 15, 2024 Page 2 of 7 REFERENCES: (One Personal and Two Professional) Name Address/Tele. No. LICENSURE RECORD: I am presently registered and in good standing in the following States: State License # Date Acquired Expiration Date Enclose copies of licenses with application, and mail Verification Form to all State Board(s). HAVE YOU EVER BEEN CHARGED, CONVICTED OF ANY FELONY, FINED, REPRIMANDED, YOUR EMPLOYMENT TERMINATED FOR VIOLATION OF PHARMACY, LIQUOR OR NARCOTIC LAWS, OR AS SUCH PENDING? Yes ❑ No ❑ If Yes, explain: I, _______________________________________ , DO SOLEMNLY SWEAR AND AFFIRM THAT I HAVE PERSONALLY COMPLETED THIS FORM AND THE INFORMATION IN THE FOREGOING PARAGRAPHS AND THE DOCUMENTS SUBMITTED ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. (Applicant Sign Name in Full) Subscribed and Sworn to, before me, this ________ Day of _______________________ A.D.__________ (Notary Public) My Commission Expires __________________________________________ Updated February 15, 2024 Page 3 of 7 REQUIREMENTS FOR LICENSURE AS A PHARMACIST IN THE VIRGIN ISLANDS 1. Submit application as prescribed by and obtained by the V.I. Board of Pharmacy along with all requested documents. NOTE: Any false or misleading information in connection with this application may be cause for debarment on the ground of Good Moral Character. 2. Submit a recent un-mounted photograph of passport size of himself/herself autographed across the back and dated. 3. Submit a chronological account of all time spent between the date of graduation from your pharmacy school and time of application. 4. Submit a copy of diploma/degree from a School or College of Pharmacy accredited by the American Council on Pharmaceutical Education or its successor. 5. Submit a copy of a license(s) from another state. 6. A non-refundable application fee of $25.00 made payable to Government of the Virgin Islands. 7. Complete licensure transfer process with NABP. Website: www.nabp.net 8. Submit a completed and NOTARIZED Authorization for Release of Information. 9. If foreign-trained, proof of Foreign Pharmacy Graduate Equivalency Examination Certification (FPGEC) is required. 10. Is not unfit or unable to practice pharmacy by reason of the extent or manner of his/her use of alcoholic beverages, narcotic and/or dangerous drugs or by reason of a physical or mental disability. Submit notarized non-addiction form (in packet). 11. Be a good moral and professional character; who will properly carry out the duties and responsibilities required of a pharmacist; must be at least 21 years of age; a graduate of an ACPE accredited school of pharmacy. Submit copy of proof of age (passport or birth certificate) 12. All applicants must have passed the NABP and MJPE exam successfully in another US State or jurisdiction; In addition, non-Virgin Islands high school graduates require 1 year of active licensed experience in another US state or jurisdiction. 13. Submit a current (dated within 6 months of VI application) National Practitioner Data Bank self-query. A. Visit https://www.npdb.hrsa.gov/ext/selfquery/sqhome.jsp and begin the process for the self-query. Follow all instructions given. B. After your self-query has been processed by the NPDB, they will send the self-query report directly to you. C. You must first open this report to make sure that the results were not rejected, and all information submitted is correct. D. Send all parts of the self-query report directly to our office with your application. E. For NPDB questions or assistance, call 800-767-6732 or email help@npdb.hrsa.gov. NOTATIONS: ❊ After reviewing your application, it may be necessary for you to take the MPJE/NAPLEX. All applications and information for licensure should be submitted to: VI Board of Pharmacy, P.O. Box 222995, Christiansted, VI 00822-2995 Updated February 15, 2024 Page 4 of 7 VIRGIN ISLANDS BOARD OF PHARMACY P.O. Box 222995 Christiansted, V.I. 00822-2995 VERIFICATION OF LICENSURE Application is requested to complete this section of the form and mail to each State Board of Pharmacy in which you are now or have been licensed to practice Pharmacy. You may copy this form if additional copies are needed. State Board is to forward this form or its own verification form directly to: VI Board of Pharmacy, Department of Health, P.O. Box 222995, Christiansted, V.I. 00822-2995 To: (Name of Board) ____________________________________________________________ Address: _____________________________________________________________________ I, ____________________________________ , hereby authorize the ______________________________ Board of Pharmacy to release to the Virgin Islands Board of Pharmacy any information concerning my licensure status, disciplinary records and any other information, which is material to my application for licensure. Additionally, I release your agency from liability for the release of such information to the V.I. Board of Pharmacy in good faith. Applicant Signature Date Address: _________________________________________________________________________ My License No. in your State: __________________________ Exp. Date: _____________________________ THIS SECTION IS TO BE COMPLETED AND SIGNED BY AN OFFICIAL OF THE STATE BOARD AND RETURNED DIRECTLY TO THE VI BOARD OF PHARMACY AT THE ABOVE ADDRESS. Name of State Board: ___________________________________________________________________________ Full Name of Licensee: _________________________________________________________________________________ License No.: ___________________ Issuance Date: ______________________ Exp. Date: ___________________________ By: Examination/Reciprocity with the following state: ___________________________________________________ By: Flex Endorsement ___________ National Board ________ Local State Board Examination ________ Is license current and in good standing? ______ If NO, furnish details. ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Has any disciplinary action ever been taken against the above named Pharmacist?______ If YES, furnish details: ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Signed: ______________________________________________ Title:___________________________________________ BOARD SEAL State Board: _________________________________________ Date: ______________________ Updated February 15, 2024 Page 5 of 7 VIRGIN ISLANDS BOARD OF PHARMACY Department of Health P.O. Box 222995 Christiansted, V.I. 00822-2995 AUTHORIZATION FOR RELEASE OF INFORMATION I, hereby authorize all hospital(s), institution(s), or Organization(s) my references, employer(s) (past and present) and all Governmental Agencies and instrumentalities (local, state, federal or foreign) to release to the Virgin Islands Board of Pharmacy any information, which is needed for my licensure application. I have carefully read the questions in the foregoing application and have answered them completely, without reservations of any kind, and I declare under penalty of perjury that my answers and all statements made by me herein are true and correct. Should I furnish any false information on this application or other information requested in relations to the application, I hereby agree that such act shall constitute cause for denial, suspension or revocation of my license to practice Pharmacy in the Territory of the United States Virgin Islands. Additionally, I release from liability any hospital or agency releasing such information to the Board of Pharmacy in good faith. Signature Date Print Name and Address: Subscribed and sworn to before me this ____day of _________________ 20 ____ Notary Public SEAL My Commission Expires Updated February 15, 2024 Page 6 of 7 VIRGIN ISLANDS BOARD OF PHARMACY DEPARTMENT OF HEALTH P.O. Box 222995 CHRISTIANSTED, VI 00822-2995 NOTARIZED NON-ADDICTION AFFIDAVIT I, ____________________________________ am not addicted to the intemperate use of alcohol, illicit drugs, any (first, middle, last, suffix) prescription medications including controlled substances or any mind-altering substances that may alter or impair my judgement and ability to carry out the duties of the profession. Affidavit - NOTE: Any false or misleading information in or in connection with any application may be cause for debarment on the ground of lack of good moral character. Signature Date Print Name Subscribed and sworn to before me this _____day of ______________ 20____ Notary Public My Commission Expires Updated February 15, 2024 Page 7 of 7