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Technician in Training Application

Applicant Information


First Name	Middle Initial	Last Name	Suffix
Social Security #	Date of Birth	Please upload a recent photo for identification. Click here for recommendations on uploading files.
Place of Birth

Place of Birth


City	County If not born in North Dakota, please select Out of State.	State	Country

Contact Information


Mailing Address
City	State	Zipcode
Phone Number	Email

Pharmacy Technician Program


Are you:	Employed by a pharmacy
	A NDSCS Pharmacy Technician Program student


Pharmacy of Employment
Name of Supervising Licensed Pharmacist	Pharmacist's Email
What Technician Training Program are you enrolled in?	Date of Enrollment

No matter which program you are enrolled in progress must be made to ensure that you complete the program before your time limit is up. You must send a Progress Report with the Renewal Application to prove you are actually moving towards completion.


Have you been convicted in a court of general jurisdiction of any felony or misdemeanor, or are there any restrictions taken or pending against you?	Yes No

Any changes in the above information must be reported to the Board of Pharmacy Office immediately.

North Dakota Board of Pharmacy

Technician in Training Application