San Jacinto College North Campus Pharmacy Technician Application - Non SSO

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SAN JACINTO COLLEGE NORTH CAMPUS

PHARMACY TECHNICIAN APPLICATION

SECTION 1: PERSONAL INFORMATION

First Name:

Middle Name:

Last Name:

Date of Birth:

SSN: (last 4 digits) -

Phone:

San Jac G#:

DL or State ID:

Street Address:

City:

State:

Zip:

SJC Student Email:

Personal Email

SECTION 2: EMPLOYMENT INFORMATION

Are you currently employed at a pharmacy?

Yes

SECTION 3: EMERGENCY CONTACT INFORMATION

Contact Name:

Relationship:

Email:

Phone:

SECTION 4: HIGH SCHOOL EDUCATION INFORMATION

Have you completed high school?

Yes

High School/Institution:

City:

State:

Zip Code:

Select the Type of Award:

Completion Date:

CE King High School

Early College Galena Park High School

Galena Park High School

North Shore High School

Channelview High School

Home School

Other

SECTION 5: COLLEGE OR TRAINING SCHOOL INFORMATION

Have you attended a training school, college, or university?

Yes

College/Training School:

Completion Date:

Degree Awarded:

City:

State:

Zip Code:

SECTION 6: Texas State Board of Pharmacy

Do you currently hold a Texas State Board of Pharmacy Technician Trainee registration?

Yes

SECTION 7: ACKNOWLEDGEMENT

By checking this box, I certify that the information contained in this application is true and complete to the best of my knowledge.

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