LSC-O Pharmacy Technology

Pharmacy Technology Application


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 ____________________