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 ____________________