State Form 2687 - Affidavit Of Experience - Pharmacy Intern Training Program - Indiana
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1AFFIDAVIT OF EXPERIENCE -
PHARMACY INTERN TRAINING PROGRAM
State Form 26877 (R4 / 4-92)
INSTRUCTIONS:
1. Affidavit to be completed by LICENSED SUPERVISING PHARMACIST of the Pharmacy Intern’s training period.
2. Give EXACT dates and number of hours employed.
3. Return form to:
Health Professions Bureau
402 W. Washington St., Rm. 041
Indianapolis, IN 46204
IMPORTANT NOTICE TO PERSONS WHO HAVE AFFIDAVITS EXECUTED OUTSIDE OF INDIANA
Each affidavit taken outside of this state must be accompanied by certification from the Board of Pharmacy in the state where served
that such experience time is acceptable to that Board.
State in which affidavit executed
County in which affidavit executed
Date affidavit executed (month, day, year)
LICENSED PHARMACIST
Name of licensed pharmacist (first, middle, last)
State certified in
Certificate number
Pharmacy permit number
Name of pharmacy employed
Address of pharmacy employed (street, city, state, ZIP code)
PHARMACY INTERN (Pharmacist Applicant)
Name of intern (first, middle, last)
Address of intern (street, city, state, ZIP code)
Intern’s certificate number
WEEK(s) EMPLOYED (ending on)
NUMBER OF HOURS
WEEK(s) EMPLOYED (ending on)
NUMBER OF HOURS
EMPLOYED EACH WEEK
EMPLOYED EACH WEEK
Month
Day
Year
Month
Day
Year
TOTAL number of weeks employed
TOTAL number of hours employed
TOTAL length of employment (month, day, year)
From
To
The above employment information was taken from payroll or other records which are kept at: (Pharmacy name)
AFFIDAVIT
On this day, I certify that I am a licensed pharmacist holding the certificate number listed above in the state certified in, and that the
above name Pharmacy Intern, located at the address indicated, was in my employ, compounding and filing prescriptions for medical
practitioners under my supervision for the total number of hours, and length of employment listed above for the above named pharmacy.
I solemnly swear, or affirm that the statements give above are true and correct to the best of my knowledge.
Signature of licensed pharmacist
Date signed (month, day, year)
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