Pharmacy Technician Application Form Return Application Forms to: Pueblo Community College Health and Public Safety Division Marcella Noriega MT 176 900 W. Orman Avenue, Pueblo, CO 81004 Dates of Application Fall Semester – Applications are available April 15th; Deadline for Submission is June 15th Spring Semester – Applications are available September 15th; Deadline for Submission is November 15th Application Instructions: 1. Place your initials in each space provided to indicate that you have read and understand each of the following statements. 2. I understand that I must be accepted into this program before I can be registered for any courses in the program. (Initial) 3. Qualified applicants will be conditionally accepted for enrollment, up to the class limit. (Initial) 4. It is the applicant’s responsibility to assure that their phone number and address are current. If, the program coordinator is unable to contact the student by phone and/or student does not respond within 7 business days of conditional acceptance, the next applicant will be contacted. (Initial) 5. If you are conditionally accepted, you will receive a letter explaining how to proceed with a background check and drug screen. Once these are completed and cleared the student will be officially accepted into the program. (Initial) 6. I understand that this program requires time outside of class to complete all clinical requirements for a certificate. (Initial) 7. I understand that the 12 Credit, Pharmacy Technician Certificate Program does not qualify for Financial Aid. _ (Initial) Name: _______________________________ Date & Time Received: ________________ by _____ 8) If you receive a letter of CONDITIONAL ACCEPTANCE, you will also receive information regarding specific dates/times to complete the following: background check, drug screen, immunizations, HealthCare Provider CPR, and liability insurance. The administrative assistant will be collecting this information in MT 176 and can also enroll students in the appropriate classes. (You cannot enroll yourself). If you have questions about the completion of these requirements, contact the administrative assistant @ 549-3280 or the Program Coordinator, Bonnie Housh @ 549-3198. (Initial) 9) I understand that my immunizations must be transferred to the PCC health form. This must be completed by the PCC Health Clinic in Room MT 118 549-3318. These forms will also be sent out with the conditional acceptance letter. (Initial) 10) To the best of my knowledge and belief, the information I have given on this form is correct and can be verified. I have not withheld information that would affect my acceptance to the Pharmacy Technician Program. (Initial) 12) I have read and understand the instructions and process for admissions into the Pharmacy Technician Program. I understand that only completed applications along with a copy of College Transcripts and/or Accuplacer/I-Grad scores. (Initial) APPLICANT’S SIGNATURE: DATE: Completion of this form does not constitute admission to the program. Students will be notified by phone and/or letter if they are accepted, denied or placed on alternate list for the program. NOTICE OF NON-DISCRIMINATION STATEMENT Pueblo Community College is an equal-opportunity educational institution which does not discriminate on the basis of age, race, religion, color, national origin, sex, or disability in its activities, programs, or employment practices as required by Title VI, Title IX, Section 504, Age Discrimination Act, and Title II of the ADA. 2 Pharmacy Technician Certificate Program Application for Admission NAME: Last DATE: First Middle Student ID: Maiden/Former Name(s): E-Mail Address Mailing Address: City State Zip Phone: Home Work Emergency If there is a change in address or phone numbers please give written notice to Office of Admission and Program Coordinator/Administrative Assistant. Applicant Check List: Please √ all items 1-3 before submitting application. 1. Application to Pueblo Community College and Pharmacy Technician Program. 2. College Transcript and/or assessment scores (Attach copies) 3. Academic Requirements (prerequisites) Completed or in Progress Indicate score, grade, or other college level courses completed with a “C” or above. * Students that have all of the prerequisites completed will be considered for priority admissions. Students who are in progress with prerequisites will be considered for admissions if openings are available upon completion of the courses and updated transcripts are submitted. Accuplacer: English SS 95+ or completion of CCR 092______________ Reading RC 62+ or completion of CCR 092 _____________ Math EA 45+ _____________ * Previous College experience may allow you to waive the Accuplacer test. 3 List of Requirements and Qualifications 1. All unofficial transcripts/I-Grad/Accuplacer scores must be attached to application. 2. Cleared for a Drug Screen. $35.00 3. Cleared for a Back Ground Check. $10.00 4. PCC Health Form completed and signed by the PCC Health Clinic. 549-3318 5. Liability Insurance with of proof of receipt, $10.00, from the PCC Cahier’s Office.549-3212 6. Current CPR card. If your card is not current please call Ann Flores to schedule a class. 549-3477 4