MedsPLUS Pharmacy Pathways Application Form

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Name *

First

Last

Date of Birth *

dd/mm/yyyy

City Graduated theft,

Home Address *

City, State, ZIP Code *

Phone Number *

Email Address

Preferred Contact Method *

Eligibility Requirements *

I am at least 18 years old
I have earned a high school diploma or GED
I understand that a background check will be conducted as part of this program
I acknowledge that I have no disqualifying criminal history that would prevent me from obtaining an Alabama pharmacy technician license
I understand that successful program completion requires participation in a PTCB-recognized training course

To qualify for this program, check each box to confirm your eligibility

Have you ever been convicted of a felony or misdemeanor related to drugs, theft, or fraud?

You may write explanation here if needed

High School/GED Program Name

City & State

Year Graduated

Most Recent Employment (if any)

Employer / Position / Dates of Employment (mm/yyyy - mm/yyyy) / Reason For Leaving

Personal Reference (1)

Full Name / Relationship / Phone Number / Email

Personal Reference (2)

Full Name / Relationship / Phone Number / Email

Program Commitment & Consent *

I understand that successful completion of this program does not guarantee employment, but job placement assistance will be provided.
I acknowledge that I must complete all training, assessments, and licensing
I consent to a background check as required by the Alabama Board of Pharmacy.
I certify that all information provided is true and accurate to the best of my knowledge.

Please read and acknowledge the following