Pharmacy Technology application must be filled out completely, printed, signed and returned.

Name (First) (Middle) (Last) (Maiden)
Address (City, State, ZIP)
Social Security Number
Telephone Number
If an emergency, call
Emergency Contact (Phone, City, State)
Are you currently enrolled at Lamar State College-Orange?	Yes No
If no, have you ever been a student in the Lamar University System?	Yes No
If yes, years(s)
If yes, the name(s) you enrolled under
THEA test is not required for pharmacy technology program certificate.
THEA Scores (If Applicable)	Math Reading Writing THEA
Do you have a certificate/degree in another field?	Yes No
What field?
Certification Number
State and Expiration Date

PLEASE READ AND SIGN THE FOLLOWING STATEMENT

I certify that the above statements are true.

Signature __________________________________ Date ____________________