Pharmacist Application

REQUIREMENTS - PHARMACIST EXAM & LICENSE

Access this form via website at: http://cca.hawaii.gov/pvl/

LICENSE–GENERAL 1. Citizenship and Age Requirement - Is at least 18 years of age and is a United States citizen, a

REQUIREMENTS United States national, or an alien authorized to work in the United States.

Social Security Number - Your social security number is used to verify your identity for licensing

purposes and for compliance with the below laws. For a license to be issued you must provide

your social security number or your application will be deemed deficient and will not be processed

further.

The following laws require that you furnish your social security number to our agency:

FEDERAL LAWS:

42 U.S.C.A. §666(a)(13) requires the social security number of any applicant for a professional

license or occupational license be recorded on the application for license; and

If you are a licensed health care practitioner, 45 C.F.R., Part 61, Subpart B, §61.7 requires the

social security number as part of the mandatory reporting we must do to the Healthcare Integrity

and Protection Data Bank (HIPDB), of any final adverse licensing action against a licensed health

care practitioner.

HAWAII REVISED STATUTES ("HRS"):

§576D-13(j), HRS requires the social security number of any applicant for a professional license or

occupational license be recorded on the application for license; and

§436B-10(4) HRS which states that an applicant for license shall provide the applicant's social

security number if the licensing authority is authorized by federal law to require the disclosure (and

by the federal cites shown above, we are authorized to require the social security number).

2. Education - Graduation from pharmacy school or college accredited or has received candidate

status by the American Council Pharmeceutical Education ("ACPE").

3. Examination - Pass the North American Pharmacist Licensure Examination (NAPLEX) and the

Multistate Pharmacy Jurisprudence Examination (MPJE) for this State, each with a minimum

passing score of 75.

4. Practical Experience – All applicants for a Hawaii pharmacist license shall submit verification of at

least 1,500 hours of practical experience in a pharmacy. You may submit this verification before

or after you sit for the examinations. There are two ways to verify the 1,500 hours:

• Pharmacy Intern – Hours earned as a pharmacy intern in this State or any other State may

be credited provided the hours were obtained after the first year of pharmacy school, were

conducted under the supervision of a licensed pharmacist and is verified by either the

pharmacy school or the board of Pharmacy, as a pharmacy intern, for that state.

• Experience as a Practicing Pharmacist in Another State – Hours earned as a practicing

pharmacist in another state may be credited provided the 1,500 hours were obtained

within the last five (5) years preceding the date of application and the hours are verified by

your employer (see Certification of Work Experience as a Registered Pharmacist form

attached to this application), or if self-employed, a statement by the applicant attesting

that the applicant owned and operated an independent pharmacy and that the applicant

has practiced pharmacy as a licensed pharmacist for 1,500 hours or more within the five

years preceding the date of application.

A combination of the above may be accepted if the applicant is a recent graduate of an accredited

pharmacy school and has earned some practical experience as a pharmacist.

Practical experience means the selling of drugs, compounding prescriptions, preparing

pharmaceutical preparations, and keeping records and making reports under state and federal

statutes.

5. Application - Complete and submit an "Application for Exam and License - Pharmacist" with a $50

non-refundable application fee made payable to "Commerce & Consumer Affairs". Your

application will not be processed without this fee. Failure to provide all the requested information

will delay the processing of your application.

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PH-00 0421R

PATHWAYS TO

 Reciprocity or Licensure Transfer

(If licensed in another state or territory of the United States with

PHARMACIST

qualifications that are equal or exceed Hawaii's requirements. Note: California and Florida do not

LICENSURE

reciprocate.)

1. NABP Application for Transfer of Pharmaceutic Licensure - Contact the National Association of

Boards of Pharmacy (NABP) to obtain information and application for the Application for

Transfer of Pharmaceutic Licensure. Effective March 1, 2005, NABP will discontinue the hard

copy version of this application which is currently available on NABP's website

at:www.nabp.net under "Licensure Transfer" and "Licensure Transfer Application". Upon

receipt of this report from the NABP, you must forward this to the Hawaii State Board of

Pharmacy along with the Board's application within 90 days of the NABP's report date of

issuance. You may submit the Board's application while awaiting your NABP report to be

completed.

Note: Both your state application and your Transfer of Licensure Report must be received in

our office.

You may contact NABP at:

NABP

1600 Feehanville Drive

Mount Prospect, IL 60056-6014

Phone: (847) 391-4406

www.nabp.net

2. Practical Experience – Refer to 4. Practical Experience on page 1 under "General

Requirements".

3. Examinations:

a. If the license you are reciprocating was obtained before June 22, 1976, you will need to

have passed the pharmacist licensing exam administered in that state with a general

average score of at least 70.

b. NABPLEX OR NAPLEX:

 If the license you are reciprocating was obtained on or after June 22, 1976, and

before May 12, 1986, minimum passing general average score of 70; or

 If the license you are reciprocating was obtained on or after May 12, 1986, minimum

passing converted score of 75.

c. Multistate Pharmacy Jurisprudence Exam (MPJE) - Pass with a minimum score of 75.

All applicants are required to take and pass the MPJE for Hawaii licensure. The MPJE

taken for another state license is not valid for Hawaii.

 Examination

1. Certified Transcript - Arrange with your pharmacy school or college to send directly to our

office, a certified transcript showing graduation date and degree conferred. Your pharmacy

school or college must be accredited or has received candidate status by the American

Council on Pharmaceutical Education (ACPE).

2. Practical Experience – Refer to 4. Practical Experience on page 1 under "General

Requirements".

3. License Verification - If licensed in another state or territory of the United States, submit

verification from the licensing authority of the status of your license(s), whether or not

current, inactive, lapsed, or ever made conditional, suspended, or revoked. Use the attached

"Verification of License - Pharmacist" form. If you have a license that is or has been

encumbered, pending disciplinary action, or an unresolved complaint, you shall provide all

information and documentation regarding to the matter.

4. Examinations - Pass the NAPLEX and the Multistate Pharmacy Jurisprudence Exam ("MPJE"),

each with a minimum score of 75. See www.nabp.net for examination information.

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PATHWAYS TO

PHARMACIST

LICENSURE

(Cont'd)

• Score Transfer

1. If you have taken and passed the NAPLEX Exam - Apply to NABP to have your passing

NAPLEX score sent directly to the Hawaii Board. The applicant is responsible for

complying with and paying for any fees incurred to participate in the NABP Score Transfer

Program. See www.nabp.net for examination information.

2. MPJE - Pass with a minimum score of 75. All applicants are required to take and pass the

MPJE for Hawaii licensure. The MPJE taken for another state license is not valid for

Hawaii.

3. Certified Transcript - Arrange with your pharmacy school or college to send directly to our

office, a certified transcript showing graduation date and degree conferred. Your

pharmacy school or college must be accredited or has received candidate status by the

American Council on Pharmaceutical Education (ACPE).

4. Practical Experience - Refer to 4. Practical Experience on page 1 under "General

Requirements".

5. License Verification - If licensed in another state or territory of the United States, submit

verification from the licensing authority of the status of your license(s), whether or not

current, inactive, lapsed, or ever made conditional, suspended, or revoked. Use the

attached "Verification of License - Pharmacist" form. If you have a license that is or has

been encumbered, pending disciplinary action, or an unresolved complaint, you shall

provide all information regarding the matter.

• Foreign Educated Applicants via Reciprocity or Licensed in Another State

1. Arrange to have an official transcript sent from your pharmacy college directly to the

Hawaii Board.

2. Submit copies of certificates showing you passed the Foreign Pharmacy Graduate

Equivalency Examination (FPGEE), Test of English as a Foreign Language (TOEFL) and Test

of Spoken English (TSE). The Hawaii Board will then verify these scores directly with

NABP.

3. Examinations - If you are reciprocating a license that was obtained prior to December 24,

1992, you must have a minimum passing converted score of 75 on the FPGEE; and the

minimum TOEFL score of 550 if paper-based or 213 if computer-based test, or minimum

TSE score of 50, if the official language was other than English in the country where

educated.

If you are reciprocating a license that was obtained on or after December 24, 1992, you

must have a minimum passing converted score of 75 on the FPGEE; and have both the

TOEFL minimum score of 550 if paper-based, or 213 if computer-based, and the TSE

minimum score of 50.

Applicants are to make their own arrangements to sit for the FPGEE, TOEFL and TSE.

For FPGEE, contact: Foreign Pharmacy Graduate Examination Commission

1600 Feehanville Drive Phone No.: (847) 391-4406

Mount Prospect, IL 60056-6014 www.nabp.net

For TSE and TOEFL, contact: Educational Testing Service

P.O. Box 6151 Phone No.: (609) 771-7100

Princeton, NJ 08541-6151 www.ets.org

4. Practical Experience – Refer to 4. Practical Experience on page 1 under "General

Requirements".

No credit for practical pharmaceutical experience gained outside the United States.

5. Practical Experience - Refer to 4. Practical Experience on page 1 under "General

Requirements".

-3-Foreign Educated Applicants via Reciprocity or Licensed in Another State (cont'd)

PATHWAYS TO

PHARMACIST 6. NAPLEX Exam - Apply to NABP to have your passing NAPLEX score sent directly to the

LICENSURE Hawaii Board. The applicant is responsible for complying with and paying for any fees

(Cont'd) incurred to participate in the NABP Score Transfer Program.

7. MPJE - Pass with a minimum score of 75. All applicants are required to take and pass the

MPJE for Hawaii licensure. The MPJE taken for another state license is not valid for Hawaii.

• Foreign Educated Applicants via Examination

1. Obtain the Foreign Pharmacy Graduate Examination Certification (FPGEC) which includes the

following exams:

a. FPGEE - minimum passing score of 75.

b. TOEFL - minimum passing score of 550 if paper-based test, or 213 if

computer-based test.

c. TSE - minimum passing score of 50.

Applicants are to make their own arrangements to obtain the FPGEC and shall comply with the

testing agencies' requirements. For the FPGEC application and information, contact:

Foreign Pharmacy Graduate Examination Committee

National Association of Boards of Pharmacy

1600 Feehanville Drive

Mount Prospect, IL 60056-6014

Telephone No.: (847) 391-4406

www.nabp.net

2. After receiving your FPGEC, complete and submit ″Application for Exam & License -

Pharmacist″. Attach the $50 non-refundable application fee made payable to "Commerce and

Consumer Affairs". Your application will not be processed without this fee. Attach a copy of

your FPGEC.

3. Examinations: Pass the NAPLEX and the MPJE exams, each with a minimum score of 75.

See www.nabp.net for examination information.

4. Practical Experience: Refer to 4. Practical Experience on page 1 under "General

Requirements".

No credit for practical pharmaceutical experience gained outside the United States

If an agency or individual is assisting you with the licensure process, we will not be able to release any

RELEASE OF

information to them unless you provide us with authorization. If you wish to do so, please complete the

INFORMATION

portion on Release of Information to Third Party, sign and date it.

This material can be made available for individuals with special needs. Please call the Licensing Branch Manager at (808) 586-3000 to submit your

request.

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GENERAL INFORMATION - PHARMACIST APPLICATION FOR EXAM AND LICENSE

ALL APPLICANTS

1. Licensure requirements are subject to change as a result of new laws or rules, or from new policies and procedures adopted by

the Department of Commerce & Consumer Affairs ("Department") in cooperation with the Board of Pharmacy ("Board").

Applicants must meet current licensure requirements.

2. It is the responsibility of the applicant to arrange for submission of all required documentation for timely completion of the

application. The Department does NOT have an obligation to notify applicants of incomplete documentation. Applicants may

contact the Department periodically to monitor the status of their file with regard to the receipt of supporting documents.

3. Applications are kept for only two years after filing, after which the Board can discard applications. Therefore, applicants

must complete all licensure requirements within two years of filing the application with the Board. Licensure requirements also

include payment of all fees. If you are not licensed within one year of filing your application, you will be required to update

your application information, including license status verifications from the other state pharmacy boards.

4. License verification: If you are licensed, or ever held a license in another state/territory of the United States, and you are not

applying for a license via reciprocity or license transfer, you must have your license status verified by that licensing authority.

Use the attached form. Check with the licensing agency for any fees you may need to pay and also the amount of time for

that agency to process your license verification to our State.

5. Examination Forms: For exam information, please read the NAPLEX/MPJE Registration Bulletin which can be downloaded from

www.nabp.net. After the Board has determined you are eligible to sit for the exam(s), you will be mailed an approval notice

with instructions to register for the exam(s) online.

6. Postponement or withdrawal of exam: Refer to the NAPLEX/MPJE Registration Bulletin.

7. Results and Re-examination: Results will be mailed approximately within 10 days after taking the exam. If you fail an exam

and you wish to pursue licensure, you need to re-register for the exam failed.

8. License fees: These are separate from, and in addition to, the application and examination fees. You will be notified of

amount due after successfully passing the required exam(s).

$165.00 - Even-numbered years;

$ 70.00 - Odd-numbered years.

9. Hawaii Pharmacy laws and rules: Copies are available by submitting a written request to: Board of Pharmacy, P.O. Box 3469,

Honolulu, HI 96801. The MPJE is referenced, in part, to the following laws and rules:

a. Chapter 461, Hawaii Revised Statutes, HRS, Pharmacists and Pharmacies

b. Title 16, Chapter 95, Hawaii Administrative Rules, HAR, Pharmacists and Pharmacies

c. Chapter 328, HRS, Food, Drugs, and Cosmetics

d. Chapter 329, HRS, Uniform Controlled Substances Act

e. Chapter 436B, Hawaii Revised Statutes, the Professional and Vocational Licensing Law

The laws and rules are also posted on our website at: http://cca.hawaii.gov/pvl/. Click on "Pharmacy and Pharmacist". Then

click on "Statute/Rule Chapter".

Other recommended references:

f. Title 23, Chapters 200 and 201, HAR, available at:

http://hawaii.gov/psd/administration/administrative-rules/PSD-Title23.pdf/view

g. Chapter 330, HRS, Sale of Poisons, available at:

http://www.capitol.hawaii/gov/hrscurrent/Vol06_Ch0321-0344/"

All candidates for licensure must be familiar with the current Federal and State laws, rules and regulations. Should there be

any conflict between the State laws, the stricter law will apply.

10. ″Certified″ Photocopies of documents: You may attach to your application certified copies of your pharmacy transcript,

FPGEC. A certified copy of a document must contain the statement, "I have reviewed the original document and attest that

this is a true and exact copy of the original" written by the notary public, and partially covered by the notary public's seal or

signature. Each page must be certified. In lieu of certified copies, you may submit:

a. The originals (be advised that the Board will not return any document to the applicant; because all submittals become

the property of the Department); or

b. Arrange to have the issuing institution send directly to the Board the documentation that is required for licensure.

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PH-23 0421R

11. Instructions for "Yes" Answers to Questions (5) through (7) of the Application for License (PH-01)

A. The following documentation must be submitted with the license application. Applications for license will not be considered

without this material.

1. Questions 5 and 6 refer to complaints, charges of unlicensed activity, or pending disciplinary actions for any

profession, occupation, or license. If your answer is "yes" to one or more of these questions, read paragraph "B"

below, AND you must submit the following:

i. A statement signed by you explaining the circumstances; and

ii. Copies of any documents from the agency, including final orders, petitions, complaints, findings of fact and

conclusions of law, and any other relevant documents;

2. If your application indicates a criminal conviction, read paragraph "B" below, and you must submit the following:

i. A statement signed by you explaining the circumstances leading to the conviction and detailing all activities

since the conviction, including employment and business involvements. Include job title, period of

employment, employer's name, description of duties, training attended, and educational courses attended.

ii. A copy of the court order, verdict, and terms of sentence; and

iii. If applicable, a copy of the terms of probation and/or parole and a statement from your probation or parole

officer as to your compliance with the court orders;

iv. A current criminal history record check in your name from the state where the conviction occurred and the

state where you currently reside, if different. In Hawaii, you may obtain a criminal history record check

from the Hawaii Criminal Justice Data Center. Contact the Department of the Attorney General, Hawaii

Criminal Justice Data Center, Kekuanao'a Building, 465 S. King Street, Rm. 101, Honolulu, HI 96813. Ph:

(808) 587-3100 or visit their website at: www.hawaii.gov/hcjdc to request a "Criminal History Record

Check" form.

B. If you answered "yes" to questions (5) through (7), your application will be reviewed at a Board of Pharmacy meeting if you

have provided all applicable information and documents as described above. The Board will not review incomplete

applications. If you wish to present oral testimony at the Meeting, submit a written request with your application.

12. License renewal: All pharmacist licenses, regardless of when issued, expire on December 31 of each odd-number year and are

subject to renewal by the license expiration date. A "License Renewal Application" is mailed approximately 60 days prior to

December 31 of each odd-numbered year to your last address on file with the Licensing Branch. The

Board/Department/Licensing Branch is not responsible for non-receipt of any mail. The burden is on the licensee to ensure that

his/her license is kept active.

A forfeited (non-renewed) pharmacist license may be restored up to three (3) years from the date of forfeiture, upon the filing

of a restoration application and completing the restoration requirements. If restoring your license in the 2

or 3

year after the

expiration date, your request for restoration of your license MUST be accompanied by: 1) Written statement of employment

from a licensed pharmacist verifying 1,500 hours within the preceding five (5) years (dates and places) since delinquent, if

licensed out-of-state; 2) Copy of out-of-state license; 3) Statement signed by out-of-state licensing agency stating license is

valid and in good standing; and a statement that applicant has been employed for at least 1,500 hours within the last 5 years.

You will be required to retake and pass the Multistate Pharmacy Jurisprudence Exam (MPJE) with a minimum score of 75.

After three years you must re-apply for licensure as a new applicant.

Also, beginning with the December 2007 renewal, all Hawaii licensed pharmacists must complete a minimum of 30 hours of

approved continuing education during each licensed biennium and prior to December 31 of every odd-numbered year (when

pharmacists renew).

13. Address changes: You must report your change of address in writing. Report each address change separately, and the

effective date of change.

14. Mailing address: Board of Pharmacy

DCCA, PVL, Licensing Branch

P.O. Box 3469

Honolulu, HI 96801

Deliver to office location:

335 Merchant St., Room 301

Honolulu, HI 96813

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15. Status of your application: You may write, or call the Licensing Branch at (808) 586-3000. We do not accept, nor send,

application materials by fax.

Toll free voice access numbers for the neighbor islands:

Kauai - 274-3141 ext. 6-3000

Maui - 984-2400 ext. 6-3000

Hawaii - 974-4000 ext. 6-3000

Molokai - 1-800-468-4644 ext. 6-3000

Lanai - 1-800-468-4644 ext. 6-3000

16. Applicants with special needs:

If you are requesting special testing arrangements due to a disability, call (808) 586-2711 immediately to obtain a Disability

Certification form which must be completed by an approved professional, and submitted preferably prior to your exam

application. Determination of qualification for special testing arrangements will then be made and if so, the type of special

testing arrangements to be provided.

No action will be taken to provide special testing arrangements until your exam application has been approved.

17. Temporary License: In addition to all of the other requirements, the applicant must first sit and pass the MPJE exam. It is

advised that applicants complete all licensure requirements, including the MPJE exam, and be issued a Hawaii license before

moving to Hawaii.

18. Abandonment of Application: Pursuant to HRS §436B-9 your application shall be considered abandoned and shall be

destroyed if you fail to provide evidence of continued efforts to complete the licensing process for two consecutive years. The

failure to provide evidence of continued efforts includes but is not limited to: (1) failure to submit any required information and

documents requested by the licensing authority within two consecutive years from the last date the documents and

information were requested, or (2) failure to complete any additional requirements for licensure that remain after approval of

your application, such as attempting to complete an exam requirement, within two consecutive years from the date your

application was approved, or (3) failure to provide the licensing authority with any written communication during two

consecutive years indicating that you are attempting to complete the licensing process. If an application is deemed abandoned

the applicant shall be required to reapply for licensure and comply with the licensing requirements in effect at the time of the

reapplication.

NOTE: One of the numerous legal requirements that you must meet in order for your new license to be issued is the payment

of fees as set forth in this application. You may be sent a license certificate before the payment you sent us for your required

fees is honored by your bank. If your payment is dishonored, you will have failed to pay the required licensing fee and your

license will not be valid, and you may not do business under that license. Also, a $25.00 service charge shall be assessed for

payments that are dishonored for any reason.

If for any reason you are denied the license you are applying for, you may be entitled to a hearing as provided by Title 16,

Chapter 201, Hawaii Administrative Rules, and/or Chapter 91, Hawaii Revised Statutes. Your written request for a hearing

must be directed to the agency that denied your application, and must be made within 60 days of notification that your

application for a license has been denied.

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APPLICATION FOR EXAM AND LICENSE - PHARMACIST

READ REQUIREMENTS FOR LICENSURE BEFORE COMPLETING

License No.

PH -

Effective Date

Legal Name (First, Middle) (Last )

OFFICE USE ONLY

Residence Address (include apt. no., city, state and zip code) – REQUIRED

Mailing Address (ONLY if different from residence)

Social Security No.

Date of Birth

Phone No. (days):

I am applying for the:

( ) NAPLEX ( ) MPJE

Other Names Used (including maiden name):

EDUCATION

Name of School Location Date Graduated Degree Earned

RECIPROCITY OR

LICENSE TRANSFER

APPLICANTS ONLY

Is the official report from NABP attached?................................................................................................YES NO

Is the official NABP report being submitted to this Board within 90 days from the date of issuan

by NABP?...................................................................................................................................YES NO

(SIGNATURE REQUIRED ON PAGE 2)

App ................... 496 ........... $50 Lic ................................... 499 ................ $20

CRF ...................................497. ................. $50/$100

½ Renew al (even) ............. 490 ............... $45

Service Charge.................. BCF ....................... $25

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)

PH-01 0421R

Circle your answ ers. If you answer "YES" to any question 5 through 7, see attached instruction for "YES" answ ers.

1) Are you at least 18 years of age? ................................................................................................................. YES NO

2) Are you a U.S. citizen, a U.S. national, or an alien authorized to work in the United States? ............................. YES NO

3) Have you ever held a pharmacist license in any state or territory of the United States? ......................................... YES NO

State/Territory(ies) Licensed Date Licensed

(If not currently licensed in any state(s) listed above, indicate the reason(s) on a separate sheet of paper.)

4) Are you registered as a PHARMACY INTERN in Hawaii? .................................................................................. YES NO

If "YES", Permit No. Effective Date

5) Has any license ever been revoked, suspended, or made probationary or conditional,

or otherwise subject to disciplinary action? ................................................................................................. YES NO

6) Are you presently being investigated or is any disciplinary action pending against you? .................................... YES NO

7) IHave you ever been convicted of a crime in any jursidiction that has not been annulled

or expunged? .......................................................................................................................................... YES NO

Applicant Name:

FOREIGN PHARMACY SCORE TRANSFER

GRAD ONLY APPLICANTS ONLY

I have applied with NABP to have my NAPLEX score transferred to Hawaii?...............................................YES

Provide the date you requested the scores:

I am submitting this Application for License form within 90 days of my NAPLEX exam date ........................YES

(required by Hawaii law)

If you graduated from a school or college of pharmacy located outside the United States in a country where the official

language is English:

Have you attached a copy of the FPGEC certificate? ............................................................................YES NO

If you graduated from a school or college of pharmacy located outside the United States in a country where the official

language is not English:

1. Have you attached verification from the FPGEC of having passed the FPGEE

and TOEFL examinations?...........................................................................................................YES NO

2. Have you arranged for your TSE score report to be sent directly to the Board? ................................ YES NO

(Answers must be "Yes" to the preceding questions to qualify for the licensure examination.)

Affidavit of Applicant:

I herby certify that the statements, answers and representations made in this application and documents attached are true and

correct. I understand that any misrepresentation is grounds for refusal or subsequent revocation of license (Section 710-1017,

Sections 436B-19 and 461-21, Hawaii Revised Statues). I further certify that I have read, understand, and will abide by the

provisions of Hawaii Revised Statutes, Chapters 461 and 436B, and Administrative Rules, Chapter 95.

Date Signature of Applicant

Release of Information to Third Party:

To assist me in the licensing process, I authorize the Board of Pharmacy and staff to release any and all information regarding my

application (including but not limited to, application status) to:

Print Name of Individual who is assisting you:

Name of Organization:

Signature of Applicant Date

This material can be made available for individuals with special needs. Please call the Licensing Branch Manager at (808) 586-3000 to submit your

request.

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VERIFICATION OF LICENSE – PHARMACIST

(Not required for Reciprocity/License Transfer Applicants)

Access this form via website at: http://cca.hawaii.gov/pvl/

TO BE COMPLETED BY APPLICANT:

APPLICANT

Name (First-Middle) Last Social Security No.

Address (Include apt. no., city, state and zip code) License No.

Date Issued

I hereby authorize the licensing agency of the state of

to the State of Hawaii Board of Pharmacy.

Date SIGN HERE

to furnish the information below

TO BE COMPLETED BY LICENSING AGENCY:

LICENSING AGENCY

This is to certify that the above-named individual was issued license number

to practice as a pharmacist.

Date issued:

Date license/certificate expires:

License status: [ ] current

[ ] lapsed since:

[ ] inactive since:

Has this certificate ever been encumbered in any

way (revoked, suspended, surrendered, limited,

placed on probation, currently pending disciplinary

action, being investigated)? ...............................................................

(Please explain yes response and attach copy of Board's order)

Do your files contain any derogatory information

on this applicant? .............................................................................

(Please explain yes response and attach copy of documentation)

[ ] YES [ ] NO

COMMENTS:

Signature:

Title:

State:

Date:

BOARD SEAL

TO THE BOARD: Return this form directly to the Hawaii Board of Pharmacy, P.O. Box 3469, Honolulu, HI 96801.

PH-18(A) 0421R

THIS FORM MAY BE DUPLICATED.

STATE OF HAWAII

BOARD OF PHARMACY

Department of Commerce and Consumer Affairs

335 Merchant St., Room 301, P.O. Box 3469

Honolulu, HI 96801

Access this form via website at: http://cca.hawaii.gov/pvl/

CERTIFICATION OF WORK EXPERIENCE AS A REGISTERED PHARMACIST

Hours earned as a practicing pharmacist in another state may be credited provided the 1,500 hours

were obtained within the last five (5) years preceding the date of application and the hours are verified

by your employer.

(print name of applicant)

This is to certify that, .

(name of applicant)

has practiced as a licensed pharmacist from through

(month and year) (month and year)

for a total of hours at the company/institution named below.

(number of hours)

Signature (date)

Print Name

Title

Name of Company/Institution

Address

City State Zip Code

Telephone Number

( )

Fax Number ( )

DUPLICATE AS NEEDED

PH-17 0421R

State of Hawaii PHARMACY INTERN - PRACTICAL EXPERIENCE

Access this form via website at: http://cca.hawaii.gov/pvl/

Board of Pharmacy

Instructions: This form is to be completed by the applicant by examination (includes score transfer). It may be

submitted with the "Application for License-Pharmacist" or separately when the applicant completes a minimum of

1,500 hours of experience that are acceptable under the Board's laws and

rules. Experience gained outside the

United States is not accepted. DO NOT LIST AN EXPERIENCE MORE THAN ONCE. You will also need to have

your pharmacy school, a state board of pharmacy, or a licensed pharmacist submit official verification of the

practical experience you are claiming.

Legal Name: First/Middle

Last

Social Security No.

I. Practical experience gained through your attendance at a pharmacy school, and coordinated externships and

clinical clerkship programs, after successful completion of one year of pharmacy school (the Board will not accept

pro gratis hours for which the applicant did not actually work):

Name of School Dates of Experience No. of Hours

II. Practical experience as a pharmacy intern gained through work under the direct supervision of a registered

pharmacist in a pharmacy:

Pharmacy Name & Address Employment Dates No. of Hours

Date Signature of Applicant

PH-21 0421R