Form 12567 - Application For Pharmacist Intern Registration Page 2
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2CERTIFICATE OF ENROLLMENT OR GRADUATION IN PHARMACY EDUCATION
NOTE TO APPLICANT: The certificate below must be completed and signed by the Secretary or Dean of the School or College of Pharmacy
of which you are currently enrolled or a graduate. If you are a graduate of a School or College of Pharmacy outside of the United States,
then you do not need this certificate completed; you are required to submit a notarized copy of your FPGEC Certificate.
This is to certify that __________________________________________________________________________ is enrolled / a graduate
of ___________________________________________________________________________________________________________ .
Name of school or college of pharmacy
City, State of Indiana
Number of years pharmacy
Number of years pre-pharmacy
Date (month, day, year)
Signature of Secretary or Dean
(SEAL)
SPONSOR’S STATEMENT AND AFFIDAVIT
To the Indiana Board of Pharmacy: I, ______________________________________________________ , of
____________________
County of ________________________________________ , State of Indiana, do hereby make the following statement for the benefit of
______________________________________________________________ who is an applicant for registration as a pharmacist intern.
Name of Indiana Licensed Pharmacist
License number
Place of employment
Pharmacy permit number
Address (number and street, city, state, and ZIP code)
Please check one only:
On this day, I certify that I am a licensed pharmacist holding the license number listed above in Indiana and that the above
named pharmacist intern will be in my employ, compounding, and filling prescriptions for medical practitioners under my
supervision at the above named pharmacy.
On this day, I certify that the applicant named herein is enrolled in a college of pharmacy and will be entering an externship
program. Within the program, the applicant will be filling and compounding prescriptions under the direct supervision of a
licensed pharmacist in a licensed pharmacy.
I solemnly swear or affirm that the statements given above are true and correct to the best of my knowledge.
Signature of Indiana Licensed Pharmacist
Date (month, day, year)
APPLICATION AFFIRMATION
I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete and correct.
Signature of applicant
Date (month, day, year)
AUTHORIZATION FOR RELEASE OF INFORMATION
I hereby authorize, request, and direct any person, firm, officer, corporation, association, organization or institution to release to the Professional
Licensing Agency, or the Indiana Board of Pharmacy, any files, documents, records or other information pertaining to the undersigned
requested by the Agency, or the Board, or any of its authorized representatives, in connection with processing my application for licensure.
I hereby release the aforementioned persons, firms, corporations, associations, organizations, and institutions from any liability with regard
to such inspection or furnishing of any such information.
I further authorize the Professional Licensing Agency, or the Indiana Board of Pharmacy, to disclose to the aforementioned persons, firms,
officers, corporations, associations, organizations, and institutions any information which is material to my application, and I hereby specifically
release the Agency, and the Board from any and all liability in connections with such disclosures.
A photostatic copy of the authorization has the same force and effect as the original.
AFFIRMATION
I hereby swear or affirm that I have read the above statements and agree to same.
Signature of applicant
Date signed (month, day, year)
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