PHARMACY TECHNICIAN TRAINEE NOTIFICATION NAME OF TRAINEE______________________, _________________, ________________ Please print.                (last)                                        (first)                         (middle) STREET ADDRESS_______________________________________________________________ CITY______________________________ STATE________ ZIP_________COUNTY____________ PHONE NUMBER_____________________________ SS#_________________________________ HIGH SCHOOL GRADUATE_____ YES (YEAR) ______________ NO_____ GED_________________ DATE OF BIRTH_________________________________ AGE________________________________ NAME OF PHARMACY________________________________________ STORE #______________ STREET ADDRESS OF PHARMACY__________________________________________________ CITY______________________________ STATE________ ZIP_________ COUNTY____________ PHONE NUMBER OF PHARMACY____________________________________________________ EMPLOYMENT DATE STARTED IN PHARMACY________________________________________ CHECK HERE IF STUDENT TECHNICIAN TRAINEE______ HIGH SCHOOL_____ COLLEGE____ LIST ANY OTHER PHARMACY IN WHICH YOU WORKED AS TRAINEE: ________________________________________________________________________________ ________________________________________________________________________________ PLEASE PRINT NAME OF P.I.C.________________________________________________ SIGNATURE OF P.I.C.________________________________________________________ TODAY'S DATE_______________________________________________________________ Original must be sent to the West Virginia Board of Pharmacy Office within 30 days of employment start date. Make a copy of this form and post in pharmacy.