Arizona State Board of Pharmacy

Application for Pharmacy Intern Licensure

Instructions

Instructions


To apply for an Arizona intern license you must have the following qualifications:

  1. You must be enrolled and seated in class in a US university accredited pharmacist degree program, or be a recent (less than 1 year) graduate of an accredited program.
  2. If you are a graduate of a foreign university, you must have an FPGEC certificate.
  3. You must also be a US citizen or a legal resident with permission to work in the United States and must meet all current US immigration policies. If you are here on a student F-1 visa or H-1B visa, please contact the Licensing Coordinator before submitting your application.
*Please be sure to read the Application Requirements below and select the correct application type as application fees are not refundable.
*Application Fee: $60.00 (this fee is nonrefundable)


Nancy Dorobiala
Licensing and Exams Coordinator
ndorobiala@azpharmacy.gov

Click here to read the Application Requirements.

Applicant Information

Phone
Email
Suffix
Residential Address

Address
Suite/Apt.# (Please use appropriate prefix (Example: Suite 101, Apt. 101, #101, etc.))

Zip Code

City
State
County

Mailing Address

Street Address
Suite/Apt.# (Please use appropriate prefix (Example: Suite 101, Apt. 101, #101, etc.))

Zip Code

City
State
County

Arizona Statement of Citizenship and Alien Status for Public Benefits

Title IV of the federal Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (the "Act"), 8 U.S.C. § 1621, provides that, with certain exceptions, only United States citizens, United States non-citizen nationals, non-exempt "qualified aliens" (and sometimes only particular categories of qualified aliens), nonimmigrants, and certain aliens paroled into the United States are eligible to receive state, or local public benefits. With certain exceptions, a professional license and commercial license issued by a State agency is a State public benefit.

Arizona Revised Statutes § 41-1080 requires, in general, that a person applying for a license must submit documentation to the license agency that satisfactorily demonstrates the applicant’s presence in the United States is authorized under federal law. Please see the Board's website for the list of acceptable documentation.

Citizenship or National Status Declaration

Are you a citizen or national of the United States?

Education Information

Regulatory Questions

Has any formal disciplinary action, including but not limited to, censure, fine, suspension, probation, restriction of practice or revocation, ever been taken against your license or other professional certificate? If yes, provide full details, which must include the nature and date of each action and the state or jurisdiction involved. You must also provide a copy of the Order relating to the disciplinary action.
Do you have any disciplinary actions, sanctions or investigations pending against a professional license or certificate? If yes, provide full details.
Have you ever been refused or denied a license or certificate or renewal thereof to practice as a pharmacy professional or any other profession in any state, territory, district or country? If yes, provide full details, which must include the type and date of application and the state or jurisdiction involved. You must also provide a copy of the Order or letter of denial.
Have you ever been arrested for, charged with, pled guilty or no contest to, or been convicted of a felony or misdemeanor offense? (You must answer “yes” even if an arrest or conviction has been pardoned, expunged, set aside, dismissed or your civil rights have been restored.) If yes, provide full details, which must include the date, court, case number, state of prosecution and nature of the charge(s). You must also provide court documentation related to the case(s).
Confidential question -- Do you currently use or are you addicted to alcohol or a controlled substance, prescription-only drug, or dangerous drug or narcotic to such an extent that your ability to safely practice as a pharmacy professional is impaired? If yes, please provide a detailed description of your use or addiction, including treatment received (dates, names of programs, names of treating physicians).
Confidential question -- Do you currently suffer from a physical, mental, emotional, or nervous disorder or condition that impairs your ability to practice safely as a pharmacy professional? If yes, please provide additional information, including a detailed description of the disorder or condition and the name and contact information for all current treatment providers and for all monitoring or support programs in which you are currently participating.

Attachments

Proof of legal residency and birth date


Government-issued photo ID


Documentation of any name changes




Copy of valid Arizona fingerprint clearance card


Review Your Information

Affirm And Submit


Please be advised of the following pursuant to Arizona Revised Statutes (A.R.S.) § 41-1030:


A.R.S. § 41-1030 (B)

An agency shall not base a licensing decision in whole or in part on a licensing requirement or condition that is not specifically authorized by statute, rule or state tribal gaming compact. A general grant of authority in statute does not constitute a basis for imposing a licensing requirement or condition unless a rule is made pursuant to that general grant of authority that specifically authorizes the requirement or condition.

A.R.S. § 41-1030 (D)

This section may be enforced in a private civil action and relief may be awarded against the state. The court may award reasonable attorney fees, damages and all fees associated with the license application to a party that prevails in an action against the state for a violation of this section.

A.R.S. § 41-1030 (E)

A state employee may not intentionally or knowingly violate this section. A violation of this section is cause for disciplinary action or dismissal pursuant to the Agency's adopted personnel policy.

A.R.S. § 41-1030 (F)

This section does not abrogate the immunity provided by section 12-820.01 or 12-820.02.

Please note that after you click the Submit button, you cannot make changes to your application.

Mailing Address: P.O. Box 18520, Phoenix, AZ 85005 Phone: (602) 771-2727

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