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Pharmacy Technician Training Program (Maryland)
Enrollment Form
*
1.
Pharmacy Contact Information
(Required.)
Name
Company
Address
Address 2
City/Town
State/Province
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP/Postal Code
Email Address
Phone Number
*
2.
Have you read and understand the initial summary of the program?
(Required.)
Yes
No
I have questions (Please send email to Dixie@PeerRx.org)
*
3.
Are you ready to proceed with enrollment?
(Required.)
Yes
No
Other (please specify)
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)
*
5.
I understand that I cannot start training until my program is approved by the Board of Pharmacy:
(Required.)
Yes
No
*
6.
How will you have access to the library of materials from APhA?
(Required.)
I would like to purchase from PEER ($250)
I would like to purchase the required publications plus the optional "Complete Review for the Pharmacy Technician, 4e" for a total of $315)
I will purchase from APhA on my own (must send proof of purchase prior to enrolling first trainee)
I am going to share with another pharmacy (indicate name in comment field)
Other (please specify)
*
7.
I understand that I must request an enrollment certificate from PEER before an individual technician begins training:
(Required.)
Yes
No
*
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:
(Required.)
Yes
No
*
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:
(Required.)
Yes
No
*
10.
Would you like PEERx to monitor your enrollees' training period for an additional one-time fee of $100? ($250 if added after program is approved by the Board of Pharmacy)
(Required.)
Yes
No
Contact me for more information
*
11.
Are you a member of a sponsoring organization?
(Required.)
EPIC Pharmacies
IPMD
RxAutonetics (Jamie Williams)
WaypointRx
No
