PHARM TECH NEW APPL 2024 Fill

Collection: Executive Agency Records
Sub-shelf: Department of Health
Kind: Government Report
Date: 2024
Pages: 1
Text: Native Text

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VI Board of Pharmacy Pharmacy Technician License Initial / Renewal 2024-2025 First: ______________________________ M.I. ______ Last: ________________________ License# _______ Please indicate your Pharmacy Technician license renewal category. 1. PHARMACY TECHNICIAN TRAINEE (PTT) ____ 2. REGISTERED PHARMACY TECHNICIAN (RPT) ____ 3. CERTIFIED PHARMACY TECHNICIAN (CPT) ____ Attach PTCB / NHA Copy 4. CERTIFIED PHARMACY TECHNICIAN W/ IMMUNIZATION (CPTI)____ Attach PTCB / NHA & BLS Copy Are you newly certified? _____YES_____NO Cell phone# _______________________ Email Address: ___________________________________ Mailing Address: ____________________________________City: _________________ State: ____ Zip:_________ Currently Practicing in the VI? _____Yes _____No EMPLOYMENT PHARMACY PIC BUS TEL# Please email your completed Pharmacy Technician license form to: BoardofPharmacy@doh.vi.gov; Credit Card Payments can be made at: https://doh.vi.gov/payments/ Initial/Renewal fees are as follows: PTT- $0 RPT- $50.00 CPT- $75.00 CPTI- $100.00 Signature ______________________________________ Date __________ FILLABLE FORM MUST TYPE