Georgia Board of Pharmacy

1

2 MLK Jr. Drive, SE, 11th Floor

East Tower

Atlanta, GA 30334

(404) 651-8000 www.gbp.georgia.gov

PHARMACY INTERN INFORMATION SHEET

In order to be considered for licensure as a Pharmacy Intern, please complete the required application. You will

be considered for licensure once a complete application is received.

NOTE: If you hold a pharmacist license or have met all of the requirements for licensure as a pharmacist,

you DO NOT qualify for an intern license. Please review law and rules including without limitation

Official Code of Georgia Annotated (O.C.G.A.) §§26-4-41(c), 26-4-46, 26-4-47, 26-4-48 and Ga. Comp. R.

& Regs. r. 480-2-.03. Copies of the Georgia Pharmacy Practice Act are available on the Board’s website

under the “Laws, Policies, and Rules” section: www.gbp.georgia.gov.

Please follow these guidelines while working as a Pharmacy Intern:

• The required non-refundable fee must accompany the completed application. The fee for checks returned

due to non-sufficient funds is $30.00.

• Allow up to 30 business days for processing of an application.

• You may obtain internship hour credit during and between quarters/semesters of school.

• The Board has no established minimum/maximum number of intern hours earned per day

• Submit internship hours earned outside of school on the form provided by the

Board on the Board’s web site at www.gbp.georgia.gov.

• Internship Reporting Forms must be completed and submitted for each time period worked.

• Complete the form (front and back); have your preceptor sign the form, and have it notarized – IF YOU

HAVE AN EMPLOYER. If not, you may leave the portion blank.

• Mail them to the Board’s office at the address below.

• It is the intern’s responsibility to keep a record of all internship hours worked and submitted to the

Board for approval.

When filing internship hours from an out-of-state internship, please contact the State Board of Pharmacy in the

State licensed as an intern and request that it submit certified copies of approved hours to the following:

PLEASE NOTE: You must submit your appli catio n by mail. When you submit this

information by mail, you must use a 9x12 or larger envelope and should not fold or staple the

pages.

When a license is approved, the licensee can print a pocket license card, free of charge, through the

Georgia Board of Pharmacy website: www.gbp.georgia.gov.

Questions? Please call (404) 651-8000 at your convenience.

GEORGIA BOARD OF PHARMACY

2 MLK Jr. Dr S.E., 11

th

Floor

East Tower

Atlanta, GA 30334

2

Georgia Board of Pharmacy

2 MLK Jr. Drive, SE, 11th Floor

East Tower

Atlanta, GA 30334

(404) 651-8000 www.gbp.georgia.gov

Application For: Pharmacy Intern Registration and Notice of Employment

Incomplete applications are valid for one year.

Application fee: $25.00 (Non-refundable)

The fee for checks returned due to non-sufficient funds is $30.00.

Name:

(PLEASE PRINT) First Middle Last

Name as desired on License

(PLEASE PRINT) First Middle Last

Name as shown on exam records or transcripts

(if different – please print)

First Middle Last

PLEASE

CHECK

ONE

OF

THE

FOLLOWING:

MALE:

FEMALE:

Social Security Number - - Date of Birth

Physical Address

P.O. Box not acceptable- Number and Street Apt. No City/State Zip

Mailing Address

(if different) Number and Street Apt. No City/State Zip

(If you are granted a license, your name, mailing

address

and license number become public

information

and will be posted on the Georgia Board of

Pharmacy’s

website. The mailing

address

is

used for renewal notices, and

application

processing.)

Telephone Number Day Telephone Number Evening Email* FAX

*Acknowledgement

of your application will be sent by email. Also, if further information is needed, email is the

most efficient way for Board staff to contact you so that your application can be processed in the most efficient

manner. Your email will not be shared with third parties.

Do Not Write in this Section:

Receipt#:

Amount:

Applicant#:

Initials/Date:

3

Part II: Professional Education

12. Highest Degree Earned: Doctorate Master’s Bachelor’s Diploma/Certificate

13. Pharmacy School: UGA Mercer South University Philadelphia College of Osteopathy

If your school is not listed above, please print the name and address of your pharmacy school:

a. Dates Attended: c. Graduation Date:

b. Major: d. Degree(s) Earned:

Part III: To be completed by the applicant.

a. Have you ever been arrested, convicted, sentenced, pled guilty to, pled nolo contender to, or given first offender status

for the commission of a felony, misdemeanor, or any offense other than a minor traffic violation? (DWI & DUI’s are not

minor traffic violations.) ( ) Yes ( ) No

b. Have you ever had a license revoked, suspended, or otherwise sanctioned by any professional licensing board or

agency, or have you ever been denied issuance of, or pursuant to disciplinary proceedings refused renewal of a license by

any professional licensing board or agency in Georgia or any other state? ( ) Yes ( ) No

If you answered yes to any of the above questions, please attach an explanation.

By submission of this application, I swear and attest that the information is correct. I am aware that I cannot legally

compound or dispense drugs or medicines except when I do so under the immediate and personal supervision of a

Registered Pharmacist. I understand that a pharmacy intern license is only valid while enrolled in a school of pharmacy or

as approved by the Georgia Board of Pharmacy. I hereby waive my right under the Federal Education Rights and Privacy

Act and allow the school of pharmacy to notify the Georgia State Board of Pharmacy if my enrollment status with the

school of pharmacy changes.

Signature of Applicant:

Sworn to and subscribed before me this day of , 20 .

Notary Public:

(seal) My commission expires:

4

Part IV

Please Print Intern Applicant’s Name:

VERIFICATION OF ENROLLMENT – This section must be completed and submitted in order to be considered

for intern licensure.

Please have this portion of the application completed by the School/College of Pharmacy where you are currently

enrolled.

This is to certify that

(Print name)

is enrolled in pharmacy school

(Print name and address of pharmacy school)

beginning

(MM/DD/YYYY)

Signature of Dean of College/Registrar: Date

School Seal

TO BE COMPLETED BY THE INTERN EMPLOYER

Internship will be supervised by:

at

Name/License Number of Pharmacist Name/License Number of Pharmacy

Pharmacy Address

Street Address City State Zip

Date of Intern’s Employment

TO BE COMPLETED BY THE SUPERVISING PHARMACIST:

I have read the foregoing completed application of whose internship will have my immediate and personal supervision,

and find that it accurately indicates the place of internship, which I deem proper and in accordance with the regulations

which are applicable. The applicant will be given an opportunity to acquire a well-rounded practical experience which

will predominately relate to the purchase, storage, compounding, dispensing, and sale of drugs, medicines, poisons,

narcotics, and records incident thereto.

Supervisor’s Signature:

PLEASE MAIL FORM TO:

GEORGIA

BOARD OF PHARMACY

2 MLK Jr. Dr S.E., 11

th

Floor

East Tower

Atlanta, GA 30334

5

CONSENT FORM

I hereby authorize the GEORGIA STATE BOARD OF PHARMACY to receive any criminal history record

information pertaining to me which may be in the files of any state or local criminal justice agency in Georgia. I

also give consent to the Georgia State Board of Pharmacy to perform periodic criminal background checks for

the duration of my active licensure status with this state.

(Applicant’s Full Name – Printed)

Physical Address (P.O. Boxes NOT Accepted)

Sex Race Date of Birth: Social Security Number:

(MM/DD/YYYY)

Place of Birth (City/State):

Aliases or Maiden Name:

(Signature of Applicant) (Date)

5

6

AFFIDAVIT OF APPLICANT

I hereby swear and affirm that all information provided in this application is true and correct to the best of my knowledge

and belief. I further swear and affirm that I have read and understand the current state laws and rules and regulations of

the Georgia State Board of Pharmacy and I agree to abide by these laws and rules, as amended from time to time.

By signing this application, electronically or otherwise, I hereby swear and affirm one of the following to be true and

accurate pursuant to O.C.G.A. § 50-36-1:

1) I am a United States citizen 18 years of age or older. Please submit a copy of your current Secure and

Verifiable Document(s) such as driver’s license, passport, or document as indicated on the following pages of this

application.

2) I am not a United States citizen, but I am a legal permanent resident of the United States 18 years of age

or older, or I am a qualified alien or non-immigrant under the Federal Immigration and Nationality Act 18 years of age or

older with an alien number issued by the Department of Homeland Security or other federal immigration agency. Please

submit a copy of your current immigration document(s) which includes either your Alien number or your I-94 number

and, if needed, SEVIS number.

In making the above attestation, I understand that any failure to make full and accurate disclosures may result in

disciplinary action by the Georgia State Board of Pharmacy and/or criminal prosecution.

Signature of Applicant Date

Print Applicant’s Name

Personally appeared before me, the undersigned official authorized to administer oaths, comes

who deposes and swears that he/she is the person who executed this

(Applicant’s Name)

application for a license by examination for Pharmacy in the State of Georgia; and that all of the statements herein

contained are true to the best of his/her knowledge and belief.

Sworn to and subscribed before me this day of _ , 2

Notary Public Signature

County State

My Commission Expires

(seal)

7

APPLICANT: PLEASE CHECK THE FORM OF IDENTIFICATION BELOW THAT

YOU POSSESS. RETURN THIS FORM ALONG WITH A COPY OF YOUR

APPROPRIATE DOCUMENTATION. ONLY ONE DOCUMENT REQUIRED,

DO NOT SEND YOUR ORIGINAL.

Secure and Verifiable Documents Under O.C.G.A. § 50-36-2

Issued February 20, 2018, by the Office of the Attorney General, Georgia

The Illegal Immigration Reform and Enforcement Act of 2011 (“IIREA”), as amended by Senate

Bill 160, signed into law as Act No. 27, (2013), provides that “[n]ot later than August 1, 2011,

the Attorney General shall provide and make public on the Department of Law’s website a list of

acceptable secure and verifiable documents. The list shall be reviewed and updated annually by

the Attorney General.” O.C.G.A. § 50-36-2(g). The Attorney General may modify this list on a

more frequent basis, if necessary.

The following list of secure and verifiable documents, published under the authority of O.C.G.A.

§ 50-36-2, contains documents that are verifiable for identification purposes, and documents on

this list may not necessarily be indicative of residency or immigration status.

An unexpired United States passport or passport card [O.C.G.A. § 50-36-2(b)(3); 8 CFR

§ 274a.2]

An unexpired United States military identification card [O.C.G.A. § 50-36-2(b)(3); 8

CFR § 274a.2]

An unexpired driver’s license issued by one of the United States, the District of

Columbia, the Commonwealth of Puerto Rico, Guam, the Commonwealth of the

Northern Marianas Islands, the United States Virgin Island, American Samoa, or the

Swain Islands, provided that it contains a photograph of the bearer or lists sufficient

identifying information regarding the bearer, such as name, date of birth, gender, height,

eye color, and address to enable the identification of the bearer [O.C.G.A.

§ 50-36-2(b)(3); 8 CFR § 274a.2]

1

An unexpired identification card issued by one of the United States, the District of

Columbia, the Commonwealth of Puerto Rico, Guam, the Commonwealth of the

Northern Marianas Islands, the United States Virgin Island, American Samoa, or the

Swain Islands, provided that it contains a photograph of the bearer or lists sufficient

identifying information regarding the bearer, such as name, date of birth, gender, height,

eye color, and address to enable the identification of the bearer [O.C.G.A.

§ 50-36-2(b)(3); 8 CFR § 274a.2]

1

For identification presented to poll workers when voting, a registered Georgia voter may

present an expired Georgia driver’s license as proof of identification when voting pursuant to

O.C.G.A. § 21-2-417.

6

8

An unexpired tribal identification card of a federally recognized Native American tribe,

provided that it contains a photograph of the bearer or lists sufficient identifying

information regarding the bearer, such as name, date of birth, gender, height, eye color,

and address to enable the identification of the bearer. A listing of federally recognized

Native American tribes may be accessed at: https://www.bia.gov/tribal-leaders-directory

[O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

An unexpired United States Permanent Resident Card or Alien Registration Receipt Card

[O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

An unexpired Employment Authorization Document that contains a photograph of the

bearer [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

An unexpired passport issued by a foreign government, provided that such passport is

accompanied by a United States Department of Homeland Security (“DHS”) Form I-94,

DHS Form I-94A, DHS Form I-94W, or other federal form specifying an individual’s

lawful immigration status or other proof of lawful presence under federal immigration

law

2

[O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

An unexpired Merchant Mariner Document or Merchant Mariner Credential issued by the

United States Coast Guard [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

An unexpired Free and Secure Trade (FAST) card [O.C.G.A. § 50-36-2(b)(3); 22 CFR

§ 41.2]

An unexpired NEXUS card [O.C.G.A. § 50-36-2(b)(3); 22 CFR § 41.2]

An unexpired Secure Electronic Network for Travelers Rapid Inspection (SENTRI) card

[O.C.G.A. § 50-36-2(b)(3); 22 CFR § 41.2]

An unexpired driver’s license issued by a Canadian government authority [O.C.G.A.

§ 50-36-2(b)(3); 8 CFR § 274a.2]

A Certificate of Citizenship issued by the United States Department of Citizenship and

Immigration Services (USCIS) (Form N-560 or Form N-561) [O.C.G.A. § 50-36-2(b)(3);

6 CFR § 37.11]

2

Senate Bill 160 (Act No. 27), effective July 1, 2013, limited the use of passports issued by

foreign nations to satisfy the requirements for submission of secure and verifiable documents to

only those passports submitted in conjunction with a United States Department of Homeland

Security (“DHS”) Form I-94, DHS Form I-94A, DHS Form I-94W, or other federal form

specifying an individual’s lawful immigration status or other proof of lawful presence under

federal immigration law.

9

A Certificate of Naturalization issued by the United States Department of Citizenship and

Immigration Services (USCIS) (Form N-550 or Form N-570) [O.C.G.A. § 50-36-2(b)(3);

6 CFR § 37.11]

Certification of Report of Birth issued by the United States Department of State (Form

DS-1350) [O.C.G.A. § 50-36-2(b)(3); 6 CFR § 37.11]

Certification of Birth Abroad issued by the United States Department of State (Form

FS-545) [O.C.G.A. § 50-36-2(b)(3); 6 CFR § 37.11]

Consular Report of Birth Abroad issued by the United States Department of State (Form

FS-240) [O.C.G.A. § 50-36-2(b)(3); 6 CFR § 37.11]

An original or certified copy of a birth certificate issued by a State, county, municipal

authority, or territory of the United States bearing an official seal [O.C.G.A.

§ 50-36-2(b)(3); 6 CFR § 37.11]

When applying for any public benefit with the Department of Driver Services, an

applicant may submit either an expired or unexpired document that is listed above as a

secure and verifiable document. [O.C.G.A. §§ 50-36-1(g) & 50-36-2(b)(3)]

When applying for a voter identification card pursuant to O.C.G.A. § 21-2-417.1, an

individual may submit the aggregate forms of identification authorized by O.C.G.A.

§ 21-2-417.1(e).

In addition to the documents listed herein, if, in administering a public benefit or

program, an agency is required by federal law to accept a document or other form of

identification for proof of or documentation of identity, that document or other form of

identification will be deemed a secure and verifiable document solely for that particular

program or administration of that particular public benefit. [O.C.G.A. § 50-36-2(c)]