Application for
Cumberland Salem Workforce Education Alliance
Certified Pharmacy Technician
Do you have good customer service skills? Do you enjoy working as part of team? If you answered yes, then a career as a Pharmacy Technician could be right for you. In this job, you will interact with patients, coworkers, and health care professionals. As a Pharmacy Technician you will assist the pharmacist package or mix prescriptions, maintain client records, refer clients for counseling, assist with inventory control and purchasing, as well as collect payment and coordinate billing.
Employment of pharmacy technicians is expected to increase by 32 percent over the next decade, which is much faster than the average for all occupations. Pharmacy technicians can find work in many areas from retail or mail-order pharmacies, to hospitals, clinics, and
rehabilitation sites.
Applicants must apply to this program and a limited number of students will be selected. Eligible applicants will have a high school diploma or equivalent, pass a basic skills math and reading test and complete a background check. A non-refundable application fee of $75 is required to apply to the program.
Application Instructions:
1) All information given on the application form must be typed or neatly printed.
2) A check or money order for $75.00, non-refundable application fee must be enclosed
3) The completed application, and any subsequent correspondence, must be mailed to
the Professional & Community Education Department, PO Box 1500, Vineland, NJ 08362. Attention: Nancy Pollard
4) Arrange for an official copy of your high school, GED and/or college transcripts to be forwarded to Professional & Community Education Department by calling or
writing to your high school. Copies of high school diplomas are not acceptable.
5) Applicants are required to ask two individuals to provide letters of
recommendation in support of their application. These references may not be
family members. References should be responsible adults who can attest to your ability to successfully complete this training (e.g., employers, instructors, advisors, clergy or medical personnel). References are to be mailed by these individuals to the Professional & Community Education Department.
7) Applicants must submit the Immunization & Tests form along with their
application, showing proof of Hepatitis B vaccination ( 3 shot series) and recent (one year or less) tuberculin test.
Pharmacy Technician Certification Program
APPLICATION
Please type or print clearly and mail to: Cumberland County College, Cumberland Salem Workforce Education Alliance, PO Box 1500, Vineland, NJ 08362. Attention: Nancy Pollard
Name_________________________________________________________________________
Last First Middle
Other/Previous Name (which may appear on records) ________________________________
Address_______________________________________________________________________
Number & Street Apt. Number
______________________________________________________________________________
City State Zip code
Phone: Home: ( ) Work: ( )_____________________________
Social Security Number _________________________________________________________
Date of Birth___________________________ Email__________________________________
How did you hear about the Pharmacy Technician Training Program?
______________________________________________________________________________
Extra Curricular Activities (please list all school, community or religious activities in which you have
participated. Include all offices which you have held and honors you have received.)
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Give names and address of the two persons to whom you have submitted the recommendation forms.
These references must not be family members. The references should be responsible adults who can attest to your ability to successfully complete this training.
Address_______________________________________________________________________ Phone (___)_______________________________________ Email_____________________ Relationship to Applicant _________________________________________________________ Name___________________________________________ Title/Position___________________ Address_______________________________________________________________________ Phone (___)_______________________________________ Email_____________________ Relationship to Applicant _________________________________________________________ Educational Background
School City Dates Attended Degree
High School __________________________________________________________
College __________________________________________________________
Special Certification __________________________________________________________
Employment History
Present Employer___________________________________ Phone (___)________________
Address ___________________________________ Dates of Employment________
Nature of Work ________________________________________________________________
Name of Employer___________________________________ Phone (___)________________
Address ___________________________________ Dates of Employment________
Statement of Interest
Please explain why you wish to work in the health care industry as a Pharmacy Technician: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Pharmacy Technician Certification Program
Certificate of Information
I certify, to the best of my knowledge, that the information supplied on this application is complete and accurate.
Applicant’s signature_________________________________ Date_____________
Pharmacy Technician
Immunization & Tests
Name _________________________________________ Age________ Sex_________
Address_________________________________________________________________
City ________________________________________ State_______ Zip ________
Immunization & Test History
Vaccine Dose – Date
Hepatitis B 1. / /
2. / / 3. / / Tuberculin Tests
Dates Applied
Arm / Device / Antigen / Manufacturer / / /
Date Read Results (mm)
_____________________________________ ________________________________
Signature of Examiner Print Name of Examiner
______________________________________________________________________________ Address
_____________________________________ ________________________________
RELEASE OF INFORMATION FORM
I, (print name) _________________________________________, authorize Cumberland Salem Workforce Education Alliance to release all of my records pertaining to my criminal history, which includes my name, social security number, date of birth, address, and student ID number to IdentityPi.com.
I understand that the use of my records is limited to and in connection with any audit and the evaluation of continuing education programs, and in connection with the enforcement of the federal and/or state laws.
My signature is an acknowledgement that I have read and voluntarily consent to the release of the above-mentioned information.
_____________________________________________ _________________________ Student Signature Date
________________________________________________________________________ Address
___________________________________ ____________________________________ Social Security # Phone Number
