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Revised 10/07/202101/28/2022
PHARMACY INTERN REGISTRATION
APPLICATION INSTRUCTIONS
This application must be completed by applicants who want to register as Pharmacy
Interns in Maryland in accordance with Md. Code Ann., Health Occ. §12-6D-02 –
15, and COMAR 10.34.38.
Complete the attached Maryland Board of Pharmacy's Application for
Pharmacy Intern
Registration. This application is required whether or not the
applicant is paid.
Applications must be submitted with one of the two affidavits (completed and
signed) attached to this application packet. The Pharmacy School Enrollment
Affidavit (Attachment 1) must indicate the applicant’s student status at the time
the affidavit is completed.
A Pharmacy Intern applicant must meet one of the following
conditions:
o
Is currently enrolled and has completed 1 year of professional
pharmacy education in a
doctor of pharmacy program (program must
be accredited by the Accreditation Council for Pharmacy Education or
have precandidate or candidate status by the Accreditation Council for
Pharmacy Education); or
o
Has graduated from a doctor of pharmacy program accredited by
the Accreditation
Council for Pharmacy Education; or
o
Is a graduate of a foreign school of pharmacy who has established
educational
equivalency as approved by the Board
A pharmacy student does not need to apply for a Pharmacy Intern
Registration in the following situations:
o
If enrolled in a school of pharmacy sanctioned experiential learning
program or
o
If registered as a pharmacy technician with the Board performing
delegated pharmacy acts
Submit the completed application with all required attachments and a check or
money order
made payable to the Maryland Board of Pharmacy in the amount
of $ 45.00 to:
Maryland Board of Pharmacy, P.O. Box 1991, Baltimore, MD 21203-1991
Incomplete checks or money orders will be returned
Applications sent overnight or through priority mail must be addressed to:
Wells Fargo Bank, Attn: State of Maryland-Board of Pharmacy, Lockbox 111991
401 Market Street,
Philadelphia, PA 19106
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Revised 10/07/202101/28/2022
No applications with money orders or checks can be mail to the office.
Request a State of Maryland Criminal History Record Report from the
Criminal Justice
Information System (“CJIS”). CJIS will provide the
report to the Board. Please do not include the CJIS report with the
application.
We recommend that applicants currently enrolled in their first year of
professional pharmacy education do not submit their completed applications
before May 1.
Applicants who have not completed their first year of professional pharmacy
education when they submit their application will not be registered as interns
until the Board receives notification from their school that they have
successfully completed their first year.
NOTE: Your application will be good for one year from the date received by the Board. If
you wish to obtain a registration and have not met all criteria within one year, your
application will expire and you must resubmit an application and the applicable fees.
Fees paid for expired applications will not be refunded or credited.
NOTE: The intern registration will expire on the last day of the birth month following 1 year
after
initial registration.
NOTE: Your application will not be processed until the Board receives your completed
CJIS report. Please review the in-depth CJIS instructions located on the Board’s website
at http://www.mdh.maryland.gov/pharmacy by clicking on the "Technician" tab and
opening the Word document under general information. The CJIS instructions for
pharmacy interns are the same as the CJIS instructions for pharmacy technicians.
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Revised 10/05/2020
If you are interested in volunteering for the Emergency Preparedness Task
Force, please
visit http://dhmh.maryland.gov/pharmacy/Pages/emergency-preparedness-
information.aspx
for more information and/or email
MDresponds.dhmh@maryland.gov to register.
NOTE: Please allow four to six weeks for processing of your application.
NOTE: The application fee is a non-refundable, administrative fee.
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Revised 10/05/2020
APPLICATION FOR PHARMACY INTERN REGISTRATION
NEW APPLICATION
☐Total Due: $45.00
Please print clearly in ink or type in upper
case letters only.
Complete all application sections and
sign. Incomplete forms will delay the
issuance of your license.
I certify that this is a photograph of me taken within the previous 180 days of
submitting this application.
Applicant’s
Signature:
1. IDENTIFICATION ☐MALE ☐FEMALE
Middle / Maiden
Name:
Last Name:
Application Date:
Street Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Social Security
Number:
Date of Birth:
Place of
Birth:
Email Address:
Maryland Board of Pharmacy
4201 Patterson Avenue
Baltimore MD 21215-2299
Phone: 410-764-4755
Fax: 410-358-6207
www.health.maryland.gov/pharmacy
Place a recent photograph in this
space
Attach a photograph
showing your face, with a
three quarter view. The
photograph must be
recent and in good
condition.
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Revised 10/05/2020
2. EMPLOYMENT INFORMATION
Employer
Name:
Date of Hire:
Street
Address:
City:
State:
Zip:
3. CURRENT PHARMACY INTERN STATUS
Check the category that best describes your current pharmacy intern status.
Applicant must provide the additional documentation needed to validate this
status.
☐
Currently enrolled in a doctor of pharmacy program (pharmacy school) and has
completed 1 year
of professional pharmacy education in a doctor of pharmacy
program (program must be accredited by the
Accreditation Council for Pharmacy
Education or have precandidate or candidate status by the
Accreditation Council
for Pharmacy Education): Must provide proof of enrollment utilizing
Attachment 1: Pharmacy School Enrollment Affidavit.
☐
Has graduated from a doctor of pharmacy program accredited by the Accreditation
Council for
Pharmacy Education: Must provide proof of graduation utilizing
Attachment 2: Pharmacy School
Graduation Affidavit.
☐
Is a graduate of a foreign school of pharmacy who (1) has established educational
equivalency as
approved by the Board and (2) has passed an examination of oral
English approved by the Board: Must
provide a copy of your original Foreign
Pharmacy Graduate Examination Committee (FPGEC)
Certificate.
4.
PHARMACY SCHOOL INFORMATION
School Name:
School Address (Including
Country):
School Phone Number:
Graduation Date:
Dates Attended:
Degree Received:
☐BS Pharm. Pharm D.
Is the School ACPE
Accredited?
☐YES ☐NO
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5.
REGISTRATION /
LICENSURE HISTORY
Have
you
applied
for
pharmacy
registration
or
licensure
in any other state?
☐YES ☐NO
If YES, disclose all places, dates and results below. Attach additional sheets if
necessary.
Name of State Date of Application
Registration/
License
Issued?
☐YES ☐NO
Date Licensed
Registration/
License
Number
In Good Standing?
☐YES ☐NO
Name of State Date of Application
Registration/License
Issued?
☐YES ☐NO
Date Licensed
Registration/License
Number
In Good Standing?
☐YES ☐NO
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6.
PERSONAL ATTESTATION
QUESTIONS
Please read this section carefully and answer the following questions related to your
practice as a
pharmacy intern. If you answer “yes” to any question, please provide a
detailed explanation (attach
additional pages if necessary) and supporting
documentation. Failure to provide complete and correct
information may result in
delay, or denial, of your application for registration
1.
Has
any
state
licensing
or
disciplinary
board
(including
Maryland) or any similar agency in the
Armed Forces,
denied your application for a registration,
reinstatement or renewal, or taken any
formal
disciplinary action against any registration or license
held by you? Such actions include,
but are not limited
to, reprimand, suspension, or revocation.
☐YES ☐NO
2.
Has
any
state
licensing
or
disciplinary
board
(including
Maryland) or similar agency in the
Armed Forces filed
any complaints or charges against you or investigated
you for any reason?
☐YES ☐NO
3.
Have
you
surrendered
or
failed
to
renew
a
healthcare
registration or license in any state?
☐YES ☐NO
4.
Have you
ever
withdrawn
your
application
for
a
pharmacy intern registration or other health
professional license?
☐YES ☐NO
5.
Has your
employment
by
any
pharmacy,
clinic,
healthcare practice, or wholesale drug
distributor
been terminated for disciplinary reasons?
☐YES ☐NO
6.
Have
you
committed
a
criminal
act
for
which you
pled
guilty or nolo contendere (see
definition below), or for
which you were convicted or received probation before
judgment?
☐YES ☐NO
7.
Excluding
minor
traffic
violations
are
you
currently
under arrest or released on bond, or are
there any
current or pending charges against you in any court of
law?
☐YES ☐NO
8.
Have
you
committed
an
offense
involving
alcohol
or
controlled substances to which you pled
guilty or nolo
contendere, or for which you were convicted or
received probation before
judgment?
☐YES ☐NO
9.
Do
you
have
a
physical or
mental
condition
that
may
impair your ability to practice as a
pharmacy intern?
☐YES ☐NO
10.
Has your
ability
to
practice
as
a
pharmacy
intern
been
affected by the use of any type
of drug or alcohol?
☐YES ☐NO
** Nolo contendere- A plea in a criminal case which has a similar legal effect as
pleading guilty. The defendant does not admit or deny the charges, but a fine
or sentence may be imposed based on this plea.
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I affirm that the information I have given in answer to these questions is true and
correct to the best of my knowledge and belief. I have read the Maryland
Pharmacy Act, Section 12-101 et. seq., Health Occupations Article, Annotated
Code of Maryland, and Board regulations, COMAR 10.34.01 et seq., and if
licensed, I agree to practice pharmacy in accordance with laws of Maryland.
Signature:
Date:
7.
STATE CRIMINAL HISTORY RECORDS CHECK
I affirm that I submitted a request for a State Criminal
History Records Check on:
☐YES ☐NO
Applicant’s
Name:
Applicant’s
Signature:
Date:
8.
LIST OF DESIGNEE
S
If applicable, list the names of person and/or entity that you authorize the
Board to release information about your application:
Name of Organization
Name of Person
Title
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Revised 10/05/2020
9.
APPLICATION CHECKLIST
Application Fee
☐YES ☐NO
Recent Photograph
☐YES ☐NO
Proof
of
Current
Pharmacy
School
Enrollment
—
Attachment 1 (if applicable)
☐YES ☐NO
Proof of Graduation from a Doctor of Pharmacy
Program
—
Attachment
2
(if
applicable
☐YES ☐NO
Proof of Graduation from a foreign school of pharmacy,
passing board of pharmacy approved educational
equivalency requirement and passing a board
examination of oral English: copy of your original Foreign
Pharmacy Graduate Examination Committee (FPGEC)
Certificate (if applicable)
☐YES ☐NO
Birth Certificate or Other Proof of Birth Date
☐YES ☐NO
CJIS Report or Proof of CJIS Report Reques
☐YES ☐NO
Would you like to receive license renewal notification via
email?
☐YES ☐NO
Would you like to be an emergency preparedness
volunteer?
☐YES ☐NO
I, _________________________________,
do solemnly swear or affirm under the
penalties of perjury that I have personally completed this application, that the
foregoing information is true, correct and complete to the best of my knowledge
and belief, and that I understand that any misrepresentation may constitute
grounds for revoking this registration.
Applicant’s
Signature:
Date:
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Revised 10/05/2020
VOLUNTARY EQUAL OPPORTUNITY INFORMATION
To further its commitment to equal opportunity, the Board of Pharmacy requests
applicants to VOLUNTARILY provide the following information. This information will
be used for statistical purposes only by authorized personnel.
RAC
E
:
Are you of Hispanic or Latino origin?
(A person of Cuban, Mexican, Puerto Rican,
South or Central American, or other Spanish
culture or origin, regardless of race.)
☐YES ☐NO
If you are not of Hispanic or Latino origin, select one or more of the following racial
categories:
1.
American Indian or Alaska Native (A person having origins in any
of the original peoples of North or South America, including
Central America, and who maintains tribal affiliations or
community attachment.)
☐
2.
Asian (A person having origins in any of the original peoples of
the Far East, Southeast Asia, or the India subcontinent, including,
for example, Cambodia, China, India, Japan, Korea, Malaysia,
Pakistan, the Philippine Islands, Thailand, and Vietnam.)
☐
3.
Black or African American (A person having origins in any of the
black racial groups of Africa.)
☐
4.
Native Hawaiian or other Pacific Islander (A person having origins
in the original peoples of Hawaii, Guam, Samoa, or other Pacific
Islands.)
☐
5.
White (A person having origins in any of the original peoples of
Europe, the Middle East, or North Africa.)
☐
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APPLICATION FOR PHARMACY INTERN
ATTACHMENT 1
PHARMACY SCHOOL ENROLLMENT AFFIDAVIT
Name of Applicant:
School of Pharmacy:
Address of School:
Year in School (Select one):
1
2
3 4
Expected Date of Graduation:
Social Security #:
STATEMENT OF PHARMACY SCHOOL ENROLLMENT
** This section must be completed by the school/college of pharmacy **
This is to certify that
_________________________________________________________
NAME OF STUDENT
is currently enrolled at__________________________________ School/College of
Pharmacy
Initial Enrollment Date:
Projected Graduation
Date:
School Address:
School Phone:
SCHOOL SEAL
Dean or Designee Name:
Title:
Dean or Designee
Signature:
Date:
Phone Number:
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Revised 10/05/2020
APPLICATION FOR PHARMACY INTERN
ATTACHMENT 2
PHARMACY SCHOOL GRADUATION AFFIDAVIT
The dean or registrar of your pharmacy school must complete this page unless you
submitted an original Foreign Pharmacy Graduate Examination Committee (FPGEC)
Certificate. The school seal must be placed on this page. If this application is
completed prior to graduation, the school must notify the Board after the applicant
qualifies for graduation and has completed the experiential portion of his/her
training.
I certify that
____________________________________________________________________
NAME OF STUDENT
attended the _________________________________________________
School/College of Pharmacy
from __________________ to __________________
and earned ____________ hours of actual pharmacy experience in a structured
program conducted by or supervised by this School/College of Pharmacy, and on
______________ graduated with the degree of
_____________________________________.
Signed
Dean or Registrar
Print Name:
Print Title:
Date:
PLACE THE SCHOOL SEAL OR STAMP ON THIS PAGE