| INSTRUCTIONS: Applicant: Fill out the following blanks. Type or print in ink. Return to the PHARMACY COUNCIL at the address listed above. | | One Photograph Required. Recent head and shoulder photograph must be attached to the application. Photograph must be of passport quality. |
| FOR OFFICE USE ONLY |
| Receipt number |
| Fee .................... Date |
| Certificate number |
| Date issued |
| APPLICATION FOR REGISTRATION AS A PHARMACIST |
| APPLICANT INFORMATION |
| Name of applicant (first, middle, last) | Maiden name (if applicable) |
| Address | Email address |
| City/Town | Social Security number |
| Date of birth (day, mo., yr.) | Place of birth | Country | Telephone number |
| Name and address of school or college of pharmacy | No. of years attended | Qualifications Obtained | Date graduated |
| I _________________________________________, above named, hereby swear or affirm under the penalties of perjury that the statements made by me in this application for license as a pharmacist by examination are true and correct. I further pledge myself to practice the profession of pharmacy with dignity, integrity and honor and to comply at all times with the rules and regulations governing the profession, should I be granted the privilege of licensure as a pharmacist in the country of Saint Lucia. |
| Signature of applicant | Date signed (day, mo., yr.) |
| If your answer is “Yes” to any of the following, explain fully in a sworn affidavit, including all related detail. Describe the event including the location, date and disposition. If you have had a malpractice judgment, provide the name of the plaintiff. Falsification of any of the following is grounds for permanent revocation of a license or permit issued pursuant to the application. |
| 1. Has disciplinary action ever been taken regarding any Yes No health license, certificate or permit you hold or have held in any country? |
| 2. Have you ever been denied a licence, certificate, Yes No registration or permit to practice as a pharmacist or any regulated health occupation in any country? |
| 3. Are there any charges pending against you regarding a Yes No violation of any State law relating to the use, manufacturing, distribution or dispensing of controlled substances, alcohol or other drugs? |
| 4. Have you ever been convicted or pled guilty or nolo contendre to: A. A violation or any State law relating to the use, manufacturing, distribution or dispensing of controlled substances, alcohol or other drugs? Yes No B. To any offense, misdemeanor or felony in any country? (Except for minor violations of traffic laws resulting in fines) Yes No |
| 5. Have you ever been denied staff membership privileges in Yes No any pharmacy or have any privileges been revoked, suspended or subjected to any restrictions, probation or other type of discipline or limitations? |
| 6. Have you ever had a malpractice judgement against you Yes No or settled any malpractice action? |
| AUTHORIZATION FOR RELEASE OF INFORMATION |
| I hereby authorize, request and direct any person, firm, officer, corporation, association, organization or institution to release to the Pharmacy Council any files, documents, records or other information pertaining to the undersigned requested by the Pharmacy Council or any of its authorised representatives in connection with processing application for licensure as a pharmacist. I hereby release the aforementioned person, firms, officers, corporations, association, organizations, and institutions from any liability with regard to such inspection or furnishing of any information. I further authorize the Pharmacy Council to disclose the aforementioned persons, firms, officer, corporations, associations, organizations, from any and all liability in connection with such disclosures. A photostatic copy of this authorization has the same force and effect as the original. I hereby swear or affirm that I have read the above statements and agree to same. |
| Signature of applicant | Date (day, mo. yr.) |