Nebraska Pharmacy Technician Certification
Participant Information
The person participating in the certification process must complete this form. The pharmacy technician must complete this form; not the employer or pharmacist.
First Name: *
Your answer
Last Name: *
Your answer
Address: *
Your answer
City: *
Your answer
State: *
Your answer
Zip: *
Your answer
Phone: *
Your answer
Date of Birth *
This information is used to verify participant.
MM
/
DD
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YYYY
Email: *
Your answer
Nebraska Pharmacy Technician Registration Number *
This number is found on State of Nebraska DHHS pharmacy technician registration. Not registered with the State? Use this link to apply with Nebraska DHHS. http://dhhs.ne.gov/publichealth/pages/crlPharmAppProcReqs.aspx
Your answer
Employment Information
Note: Participants who are currently UNEMPLOYED in the pharmacy field should indicate "not working" for the next 7 questions. Give requested information for the PREVIOUS EMPLOYER question.
Employment Pharmacy Setting *
Pharmacy Work Schedule *
Title *
Name of Pharmacy Employed By *
Your answer
Employer Address *
Your answer
Employer Telephone *
Your answer
Employer Contact Name (your supervisor) *
Your answer
Employer/Supervisor Email Address *
Your answer
Previous employer IF NOT CURRENTLY working in a pharmacy.
Include pharmacy name, address, phone number and supervisor name to verify last day of employment.
Your answer
Course Information
Participants will be mailed a program mapping letter after enrollment information is received by UNMC College of Pharmacy.
The program mapping letter includes module descriptions to assist participants in selection of appropriate elective modules for completion.
Please select your program start date. *
I understand that I have 3-months from start date to complete program requirements. If I need additional time, I will submit a request for additional time to judy.neville@unmc.edu *
Required
I understand that it is my responsibility to complete certification requirements prior to the state-mandated deadline. Pharmacy Technicians registered on or before 1/1/2016 must be certified by 1/1/2017. Pharmacy Technicians registered after 1/1/2016 have one year from date of registration to become certified. *
Required
I agree to adhere to the standards of academic integrity set forth by UNMC College of Pharmacy. Academic dishonesty includes, but is not limited to: cheating, falsifying documents, misrepresentation of facts and plagiarism. I understand that academic dishonesty may result in removal from the NE-CPhT certification process without refund of payment. *
Payment Information
I understand that I am not enrolled in the program until program fee has been received and processed by UNMC College of Pharmacy. *
Refund Policy: Participants are able to withdraw from the program before the first day of the official program start date. Refund will be issued less a 10% processing fee. A written request for withdrawal must be made in attention to the program director, Judy Neville. I have read the refund policy and agree to the terms. *
I understand that financial aid through the University of Nebraska Medical Center is not available for this program offering. *
Please continue to the next section and click SUBMIT. You must click SUBMIT to process your enrollment.
You have the option to pay at a later date, but must click SUBMIT now.
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