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 ____________________