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PHARMACY INTERN REGISTRATIONAPPLICATION INSTRUCTIONSThis application must be completed by applicants who want to register as PharmacyInterns in Maryland in accordance with Md. Code Ann., Health Occ. §12-6D-02 –15, and COMAR 10.34.38. Complete the attached Maryland Board of Pharmacy's Application forPharmacy Intern Registration. This application is required whether or not theapplicant is paid. Applications must be submitted with one of the two affidavits (completed andsigned) attached to this application packet. The Pharmacy School EnrollmentAffidavit (Attachment 1) must indicate the applicant’s student status at the timethe affidavit is completed. A Pharmacy Intern applicant must meet one of the followingconditions:o Is currently enrolled and has completed 1 year of professionalpharmacy education in a doctor of pharmacy program (program mustbe accredited by the Accreditation Council for Pharmacy Education orhave precandidate or candidate status by the Accreditation Council forPharmacy Education); oro Has graduated from a doctor of pharmacy program accredited bythe Accreditation Council for Pharmacy Education; oro Is a graduate of a foreign school of pharmacy who has establishededucational equivalency as approved by the Board A pharmacy student does not need to apply for a Pharmacy InternRegistration in the following situations:o If enrolled in a school of pharmacy sanctioned experiential learningprogram oro If registered as a pharmacy technician with the Board performingdelegated pharmacy acts Submit the completed application with all required attachments and a check ormoney order made payable to the Maryland Board of Pharmacy in the amountof 45.00 to:Maryland Board of Pharmacy, P.O. Box 1991, Baltimore, MD 21203-1991. Applications sent overnight or through priority mail must be addressed to:Wells Fargo Bank, Attn: State of Maryland-Board of Pharmacy, Lockbox 19917175 Columbia Gateway Drive, Columbia, MD 21046Revised 02/20181

NOTE: Your application will be good for one year from the date received by the Board. Ifyou wish to obtain a registration and have not met all criteria within one year, yourapplication will expire and you must resubmit an application and the applicable fees.Fees paid for expired applications will not be refunded or credited.NOTE: The intern registration will expire on the last day of the birth month following 1 yearafter initial registration. Request a State of Maryland Criminal History Record Report from theCriminal Justice Information System (“CJIS”). CJIS will provide thereport to the Board. Please do not include the CJIS report with theapplication.NOTE: Your application will not be processed until the Board receives your completedCJIS report. Please review the in-depth CJIS instructions located on the Board’s websiteat http://www.mdh.maryland.gov/pharmacy by clicking on the "Technician" tab andopening the Word document under general information. The CJIS instructions forpharmacy interns are the same as the CJIS instructions for pharmacy technicians. We recommend that applicants currently enrolled in their first year ofprofessional pharmacy education do not submit their completed applicationsbefore May 1. Applicants who have not completed their first year of professional pharmacyeducation when they submit their application will not be registered as internsuntil the Board receives notification from their school that they havesuccessfully completed their first year.Revised 02/20182

If you are interested in volunteering for the Emergency Preparedness TaskForce, pleasevisit preparednessinformation.aspx for more information and/or emailMDresponds.dhmh@maryland.gov to register.NOTE: Please allow four to six weeks for processing of your application.NOTE: The application fee is a non-refundable, administrative fee.2Revised 02/2018

Maryland Board of Pharmacy4201 Patterson AvenueBaltimore MD 21215-2299Phone: 410-764-4755Fax: ATION FOR PHARMACY INTERN REGISTRATIONPlace a recent photograph in thisspaceNEW APPLICATION Total Due: 45.00Please print clearly in ink or type in uppercase letters only.Attach a photographshowing your face, with athree quarter view. Thephotograph must berecent and in goodcondition.Complete all application sections andsign. Incomplete forms will delay theissuance of your license.I certify that this is a photograph of me taken within the previous 180 days ofsubmitting this application.Applicant’sSignature:1. IDENTIFICATION MALEFirst Name:Middle / MaidenName:Last Name:Application Date:Street Address:City:Home Phone:Work Phone:Cell Phone:Social SecurityNumber:Date of Birth: FEMALEState:Place ofBirth:Email Address:3Revised 02/2018Zip:

2. EMPLOYMENT INFORMATIONEmployerName:Date of Hire:StreetAddress:City:State:Zip:3. CURRENT PHARMACY INTERN STATUSCheck the category that best describes your current pharmacy intern status.Applicant must provide the additional documentation needed to validate thisstatus. Currently enrolled in a doctor of pharmacy program (pharmacy school) and hascompleted 1 year of professional pharmacy education in a doctor of pharmacyprogram (program must be accredited by the Accreditation Council for PharmacyEducation or have precandidate or candidate status by the Accreditation Councilfor Pharmacy Education): Must provide proof of enrollment utilizingAttachment 1: Pharmacy School Enrollment Affidavit. Has graduated from a doctor of pharmacy program accredited by the AccreditationCouncil for Pharmacy Education: Must provide proof of graduation utilizingAttachment 2: Pharmacy School Graduation Affidavit. Is a graduate of a foreign school of pharmacy who (1) has established educationalequivalency as approved by the Board and (2) has passed an examination of oralEnglish approved by the Board: Must provide a copy of your original ForeignPharmacy Graduate Examination Committee (FPGEC) Certificate.4. PHARMACY SCHOOL INFORMATIONSchool Name:School Address (IncludingCountry):School Phone Number:Graduation Date:Dates Attended:Degree Received:Is the School ACPEAccredited? BS Pharm. YES NO4Revised 02/2018Pharm D.

5. REGISTRATION / LICENSURE HISTORYHave you applied for pharmacy registration or licensure YES NOin any other state?If YES, disclose all places, dates and results below. Attach additional sheets ifnecessary.Name of StateDate of ApplicationDate enseIssued? YES NOIn Good Standing? YESName of StateDate of ApplicationDate enseIssued? YES NOIn Good Standing? YES5Revised 02/2018 NO NO

6. PERSONAL ATTESTATION QUESTIONSPlease read this section carefully and answer the following questions related to yourpractice as a pharmacy intern. If you answer “yes” to any question, please provide adetailed explanation (attach additional pages if necessary) and supportingdocumentation. Failure to provide complete and correct information may result indelay, or denial, of your application for registration1. Has any state licensing or disciplinary board (includingMaryland) or any similar agency in the Armed Forces,denied your application for a registration,reinstatement or renewal, or taken any formal YES NOdisciplinary action against any registration or licenseheld by you? Such actions include, but are not limitedto, reprimand, suspension, or revocation.2. Has any state licensing or disciplinary board (includingMaryland) or similar agency in the Armed Forces filed YES NOany complaints or charges against you or investigatedyou for any reason?3. Have you surrendered or failed to renew a healthcare YES NOregistration or license in any state?4. Have you ever withdrawn your application for apharmacy intern registration or other health YES NOprofessional license?5. Has your employment by any pharmacy, clinic,healthcare practice, or wholesale drug distributor YES NObeen terminated for disciplinary reasons?6. Have you committed a criminal act for which you pledguilty or nolo contendere (see definition below), or for YES NOwhich you were convicted or received probation beforejudgment?7. Excluding minor traffic violations are you currentlyunder arrest or released on bond, or are there any YES NOcurrent or pending charges against you in any court oflaw?8. Have you committed an offense involving alcohol orcontrolled substances to which you pled guilty or nolo YES NOcontendere, or for which you were convicted orreceived probation before judgment?9. Do you have a physical or mental condition that may YES NOimpair your ability to practice as a pharmacy intern?10. Has your ability to practice as a pharmacy intern been YES NOaffected by the use of any type of drug or alcohol?** Nolo contendere- A plea in a criminal case which has a similar legal effect aspleading guilty. The defendant does not admit or deny the charges, but a fineor sentence may be imposed based on this plea.6Revised 02/2018

I affirm that the information I have given in answer to these questions is true andcorrect to the best of my knowledge and belief. I have read the MarylandPharmacy Act, Section 12-101 et. seq., Health Occupations Article, AnnotatedCode of Maryland, and Board regulations, COMAR 10.34.01 et seq., and iflicensed, I agree to practice pharmacy in accordance with laws of Maryland.Signature:Date:7. STATE CRIMINAL HISTORY RECORDS CHECKI affirm that I submitted a request for a State CriminalHistory Records Check on:Applicant’sName: YES NOApplicant’sSignature:Date:8. LIST OF DESIGNEESIf applicable, list the names of person and/or entity that you authorize theBoard to release information about your application:Name of OrganizationName of PersonTitle7Revised 02/2018

9. APPLICATION CHECKLISTApplication FeeRecent Photograph YES YES NO NOProof of Current Pharmacy School Enrollment—Attachment 1 (if applicable)Proof of Graduation from a Doctor of PharmacyProgram—Attachment 2 (if applicableProof of Graduation from a foreign school of pharmacy,passing board of pharmacy approved educationalequivalency requirement and passing a boardexamination of oral English: copy of your original ForeignPharmacy Graduate Examination Committee (FPGEC)Certificate (if applicable)Birth Certificate or Other Proof of Birth DateCJIS Report or Proof of CJIS Report Reques YES NO YES NO YES NO YES YES NO NOWould you like to receive license renewal notification viaemail?Would you like to be an emergency preparednessvolunteer? YES NO YES NOI, , do solemnly swear or affirm under thepenalties of perjury that I have personally completed this application, that theforegoing information is true, correct and complete to the best of my knowledgeand belief, and that I understand that any misrepresentation may constitutegrounds for revoking this registration.Applicant’sSignature:Date:8Revised 02/2018