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Experiential
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Kentucky Board of Pharmacy
Practical Experience Affidavit Form IV
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Instructions for completing the form. |
| 1. General information. Type in your name on
the Pharmacy Intern line, your Intern Number, and your complete Mailing
Address. 2. In the remaining boxes, type in the name of your Pharmacist Preceptor, Inclusive Dates and Hours for your 10 rotations for the rotation year. Reminder: be sure to date (after the end of your last rotation) and sign both copies (see lower left hand side of the form). 3. Print two (2) copies of the form. Sign both copies and return them to Dr. Anne Policastri. You may hand deliver the forms or mail them. Do not fax the forms. The Board requires originals, so you must provide Dr. Policastri two original, signed copies. Mailing address for Dr. Policastri: Dr. Anne Policastri University of Kentucky College of Pharmacy 725 Rose Street Lexington, KY 40536-0082 |
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If you would like to save the completed form, click on the "Save a
Copy" button on the toolbar. You will then be prompted to choose a
location (folder) to save the file.
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