PHARMACY TECHNICIAN
CHANGE OF INFORMATION FORM
Please use the form below to notify the Board of changes in
the following Pharmacy Technician information:
1.
Name
(must include documentation e.g., copy of marriage certificate, change of name
certificate, etc.);
2.
Address;
3.
Place
of Employment
4.
Telephone
number; and/or
5.
Other
pertinent information
PLEASE COMPLETE THE ENTIRE FORM
Effective Date of
Change:
|
NAME:
REGISTRATION NUMBER: |
|
PREVIOUS
NAME: ( Mail Legal Documentation to the Board with this form) |
|
PREVIOUS
ADDRESS: |
|
PREVIOUS
CITY/STATE/ZIP:
|
|
NEW
ADDRESS: |
|
NEW
CITY/STATE/ZIP: COUNTY:
TELEPHONE: |
|
Email Address: |
|
Do you want a new registration printed? YES NO If Yes, Include $10
Duplicate License Fee |
|
EMPLOYER NAME: PERMIT NUMBER: |
|
EMPLOYER
ADDRESS: |
|
EMPLOYER
CITY/STATE/ZIP COUNTY: TELEPHONE: |
|
FULL
TIME PART TIME UNEMPLOYED RETIRED OTHER |
Select One
|
01
PRIVATE SECTOR - PROFIT |
03
FEDERAL GOV’T - MILITARY |
05
STATE GOV’T |
07
SELF EMPLOYED |
|
02
PRIVATE SECTOR – NON PROFIT |
04
FEDERAL GOV’T – NON MILITARY |
06
LOCAL GOV’T |
08
OTHER: |
Select up to Three
|
01 HOSPTIAL |
08 PRACTITIONER’S OFFICE-EMPLOYEE |
15 WHOLESALE ESTABLISHMENT |
21 FEDERAL GOV’T –NON MILITARY |
|
02 LONG TERM CARE |
09 INFUSION |
16 SCHOOL SYSTEM |
22 FEDERAL GOV’T-MILITARY |
|
03 NUCLEAR |
10 REHABILITATION AGENCY/CLINIC |
17 UNIV OR COLLEGE-ADMIN |
23 OTHER ( employ in field of license) |
|
04 CLINIC |
11 HOME HEALTH |
18 UNIV OR COLLEGE- TEACHING |
24 OTHER (outside field of license) |
|
05 GROUP PLAN/HMO |
12 SATELLITE |
19 UNIVOR COLLEGE – CLINICAL |
25 INTERNET |
|
06 PRACTITIONER’S OFFICE-SELF |
13MANUFACTURER/INDUSTRY |
20 UNIV OR COLLEGE.- RESEARCH |
|
|
07 PRACTITIONER’S OFFICE-PARTNERSHIP |
14 RETAIL ESTABLISHMENT |
|
|
Mail, Fax or eMail this form to:
(410)764-2485 Telephone
(410) 358-6207 Fax
Email Address: MDBOP@DHMH.STATE.MD.US