WEST VIRGINIA BOARD OF PHARMACY

232 Capitol Street

Charleston, West Virginia 25301

APPLICATION FOR LICENSE RENEWAL AS A

REGISTERED INTERN

July 1, 2005 to June 30, 2006

Current name and home address Enter any change of name and home address below this line

License # Phone #

NOTE: Application must be completed and include a $10.00 Registration Renewal Fee for the Second ,Third, and Fourth Year Terms.

Please Mark which year this renewal represents:

___Second Year ___Third Year ___Fourth Year

Have you ever been convicted 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 detail statement, including description of action taken.

Signature ___________________________________ Date ________________________