Pharmacy Technician Training Program (Maryland)

Enrollment Form

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* 1. Pharmacy Contact Information

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. Have you read and understand the initial summary of the program?

Yes

No

I have questions (Please send email to Dixie@PeerRx.org)

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* 3. Are you ready to proceed with enrollment?

Yes

No

Other (please specify)

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* 4. YES! I would like PEER to handle my enrollment of the pharmacy to use the program with the MD Board of Pharmacy for an additional fee of $100.

Yes

No

Other (please specify)

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* 5. I understand that I cannot start training until my program is approved by the Board of Pharmacy:

Yes

No

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* 6. How will you have access to the library of materials from APhA?

I would like to purchase from PEER ($250)

I will purchase from APhA on my own

I am going to share with another pharmacy (indicate name in comment field)

Other (please specify)

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* 7. I understand that I must request an enrollment certificate from PEER before an individual technician begins training:

Yes

No

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* 8. I understand that a technician must complete 160 hours of on-site training under pharmacists' supervision and pass the test with a 75% or better WITHIN SIX MONTHS of the trainee enrollment date. I will then send the test score to PEER for issuance of the certificate of completion:

Yes

No

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* 9. I understand that the technician must submit their completed registration application to the Maryland Board of Pharmacy within six months of the beginning of the training period for the trainee to continue working as a technician in my pharmacy:

Yes

No

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* 10. Are you a member of a sponsoring organization?

EPIC Pharmacies

IPMD

RxAutonetics (Jamie Williams)

WaypointRx

No