Application for Registration as a Nuclear Pharmacy Technician

Personal Information


First Name:	Middle Initial:	Last Name:	Suffix:
Maiden Name:	Gender:	Date of Birth:	Social Security Number:
Place of Birth:		NABP e-Profile ID:
		If you do not know your NABP e-Profile ID, please go to the NABP site to look it up.
Upload a 3x4 inch head and shoulders photograph. Click here for recommendations on uploading files.

Education


Do you have a:	High School Diploma	General Education Development (GED) Certificate


Graduate of (High School):		Year:
City:	State:	Zip:
General Education Development (GED) Certificate Issued by Board of Education in:
County:	State:	Year:

Qualifications

Please download this form, have the Pharmacist-In-Charge of employer-pharmacy complete it and use the button below to upload the completed form.

Please upload completed form from employer Pharmacist-In-Charge. Click here for recommendations on uploading files.