Pharmacy Technician Application Form

Pharmacy Technician Application Form
Return Application Forms to:
Pueblo Community College
Health and Public Safety Division
Marcella Noriega MT 176
900 W. Orman Avenue, Pueblo, CO 81004
Dates of Application
Fall Semester – Applications are available April 15th; Deadline for Submission is June 15th
Spring Semester – Applications are available September 15th; Deadline for Submission is November 15th
Application Instructions:
1. Place your initials in each space provided to indicate that you have read and understand each of the
following statements.
2. I understand that I must be accepted into this program before I can be registered for any courses in the
3. Qualified applicants will be conditionally accepted for enrollment, up to the class limit.
4. It is the applicant’s responsibility to assure that their phone number and address are current.
If, the program coordinator is unable to contact the student by phone and/or student does not respond
within 7 business days of conditional acceptance, the next applicant will be contacted.
5. If you are conditionally accepted, you will receive a letter explaining how to proceed with a background
check and drug screen. Once these are completed and cleared the student will be officially accepted into
the program.
6. I understand that this program requires time outside of class to complete all clinical requirements for a
7. I understand that the 12 Credit, Pharmacy Technician Certificate Program does not qualify for Financial
_ (Initial)
Name: _______________________________ Date & Time Received: ________________ by _____
If you receive a letter of CONDITIONAL ACCEPTANCE, you will also receive information regarding
specific dates/times to complete the following: background check, drug screen, immunizations,
HealthCare Provider CPR, and liability insurance. The administrative assistant will be collecting this
information in MT 176 and can also enroll students in the appropriate classes. (You cannot enroll
yourself). If you have questions about the completion of these requirements, contact the administrative
assistant @ 549-3280 or the Program Coordinator, Bonnie Housh @ 549-3198.
I understand that my immunizations must be transferred to the PCC health form. This must be
completed by the PCC Health Clinic in Room MT 118 549-3318. These forms will also be sent out with
the conditional acceptance letter.
To the best of my knowledge and belief, the information I have given on this form is correct and can be
verified. I have not withheld information that would affect my acceptance to the Pharmacy Technician
I have read and understand the instructions and process for admissions into the Pharmacy Technician
Program. I understand that only completed applications along with a copy of College Transcripts and/or
Accuplacer/I-Grad scores.
Completion of this form does not constitute admission to the program.
Students will be notified by phone and/or letter if they are accepted,
denied or placed on alternate list for the program.
Pueblo Community College is an equal-opportunity educational institution which does not discriminate on the
basis of age, race, religion, color, national origin, sex, or disability in its activities, programs, or employment
practices as required by Title VI, Title IX, Section 504, Age Discrimination Act, and Title II of the ADA.
Pharmacy Technician Certificate Program
Application for Admission
Student ID:
Maiden/Former Name(s):
E-Mail Address
Mailing Address:
If there is a change in address or phone numbers please give written notice to Office of Admission and
Program Coordinator/Administrative Assistant.
Applicant Check List: Please √ all items 1-3 before submitting application.
Application to Pueblo Community College and Pharmacy Technician Program.
College Transcript and/or assessment scores (Attach copies)
Academic Requirements (prerequisites) Completed or in Progress
Indicate score, grade, or other college level courses completed with a “C” or above.
* Students that have all of the prerequisites completed will be considered for priority admissions.
Students who are in progress with prerequisites will be considered for admissions if openings are
available upon completion of the courses and updated transcripts are submitted.
English SS 95+ or completion of CCR 092______________
Reading RC 62+ or completion of CCR 092 _____________
Math EA 45+ _____________
* Previous College experience may allow you to waive the Accuplacer test.
List of Requirements and Qualifications
1. All unofficial transcripts/I-Grad/Accuplacer scores must be attached to
2. Cleared for a Drug Screen. $35.00
3. Cleared for a Back Ground Check. $10.00
4. PCC Health Form completed and signed by the PCC Health Clinic. 549-3318
5. Liability Insurance with of proof of receipt, $10.00, from the PCC Cahier’s
6. Current CPR card. If your card is not current please call Ann Flores to
schedule a class. 549-3477