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| WEST VIRGINIA BOARD OF PHARMACY |
| 232 Capitol Street |
| Charleston, West Virginia 25301
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| APPLICATION FOR LICENSE PERMIT OR RENEWAL AS
A |
| REGISTERED PHARMACIST |
| July 1,
2005 to June 30, 2007 |
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Current name and home
address |
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Make any change of
name and home address below this line |
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License # |
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Section 10,
Article 5, Chapter 30 of the Code of West Virginia requires that every
registered pharmacist and registered assistant pharmacist within this
state shall on or before July 1 apply to the State Board of Pharmacy for
annual renewal of his or her certificate. Complete the following form,
fill in all categories as required, return with the fee of $120 payable to
the West Virginia Board of Pharmacy. |
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Type of Licensure:
Renewal _____ |
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New License
_____ |
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Reinstatement
_____ |
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Status (Check one):
Current _____ |
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Deceased _____ |
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Probation
_____ |
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Place of
Employment |
|
Address |
|
Home Phone |
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Work Phone |
|
City |
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State |
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Zip |
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County |
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Please
check only one in each category |
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| WORKING:
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| Full-time __
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| Part-time __
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| Retired __
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| Unemployed __
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| Seeking
Employment __ |
| Other __
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| Birth
date:_____________ | |
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| PRACTICING
IN: |
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| Retail Community
__ |
| Hospital Pharmacy
__ |
| Manufacturing __
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| Wholesale __
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| Government __
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| Teaching __
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| Social Security
#:___________ | |
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| Clinic Pharmacy
__ |
| Misc.
Pharmaceutical Capacities __ |
| Other __
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| Sex: __ Original
License Date:_____ | |
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| LICENSED
BY: |
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| Examination __
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| Reciprocity __
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| Reinstatement __
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| PHARMACY
SCHOOL: |
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| ___________________________________________________________________________
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| Location:
___________________________________________________________________
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Reciprocated From
________________________________ |
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Reciprocated To
_________________________________________ |
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| Have you ever
been charged by any agency or court, federal or state, of a felony
or any infraction of pharmacy laws? _________ |
| NOTE: If yes to
the above question, you must attach a detailed statement, including
description of action taken. | |
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| |
|
Signature |
|
Date |
|
Current name and home
address |
|
Make any change of
name and home address below this line |
| |
| |
| |
| |
| |
| |
| |
| |
|
License # |
|
Section 10,
Article 5, Chapter 30 of the Code of West Virginia requires that every
registered pharmacist and registered assistant pharmacist within this
state shall on or before July 1 apply to the State Board of Pharmacy for
annual renewal of his or her certificate. Complete the following form,
fill in all categories as required, return with the fee of $50 payable to
the West Virginia Board of Pharmacy. |
|
|
|
| |
|
Type of Licensure:
Renewal _____ |
|
New License
_____ |
|
Reinstatement
_____ |
|
Status (Check one):
Current _____ |
|
Deceased _____ |
|
Probation
_____ |
| |
|
Place of
Employment |
|
Address |
|
Home Phone |
|
Work Phone |
|
City |
|
State |
|
Zip |
|
County |
|
Please
check only one in each category |
|
| WORKING:
|
|
| Full-time __
|
| Part-time __
|
| Retired __
|
| Unemployed __
|
| Seeking
Employment __ |
| Other __
|
|
| Birth
date:_____________ | |
|
| PRACTICING
IN: |
|
| Retail Community
__ |
| Hospital Pharmacy
__ |
| Manufacturing __
|
| Wholesale __
|
| Government __
|
| Teaching __
|
|
| Social Security
#:___________ | |
|
|
|
| Clinic Pharmacy
__ |
| Misc.
Pharmaceutical Capacities __ |
| Other __
|
|
|
|
|
| Sex: __ Original
License Date:_____ | |
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|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| LICENSED
BY: |
|
| Examination __
|
| Reciprocity __
|
| Reinstatement __
| |
|
| PHARMACY
SCHOOL: |
|
| ___________________________________________________________________________
|
|
| Location:
___________________________________________________________________
| |
|
|
|
|
|
|
|
|
|
Reciprocated From
________________________________ |
|
Reciprocated To
_________________________________________ |
|
| Have you ever
been charged by any agency or court, federal or state, of a felony
or any infraction of pharmacy laws? _________ |
| NOTE: If yes to
the above question, you must attach a detailed statement, including
description of action taken. | |
|
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| |
| |
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