Pharmacist License by Examination Application Packet For (U.S. Graduates-Original License by Exam)

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Pharmacist License by Examination Application

Packet for (U.S. Graduates-Original License by Exam)


Contents:
1. 690-134.....Contents List/SSN Information/Mailing Information .......................1 page
2. 690-232.....Application Instructions Checklist.................................................2 pages
3. 690-135.....License Requirements....................................................................1 page
4. 690-136.....Requirements Checklist.................................................................1 page
5. 690-233.....Pharmacist License Application....................................................5 pages
6. 690-054.....Intern Site Evaluation Report.........................................................1 page
7. 690-095.....Preceptor Evaluation and Certification of Experience..................2 pages
8. RCW/WAC and Online Website Links.............................................................1 page

Important Social Security Number Information:


You are required by state and federal law to provide a social security number with your
application. If you do not have a social security number at the time you send in this
application, please read, complete, and return this form with your application.
A U.S. Individual Taxpayer Identification Number (ITIN) or a Canadian Social Insurance
Number (SIN) cannot be substituted.

In order to process your request:


Mail your application with initial
documentation and your check Send other documents not sent
or money order payable to: with initial application to:
Department of Health Pharmacy Quality Assurance
P.O. Box 1099 Commission Credentialing
Olympia, WA 98507-1099 P.O. Box 47877
Olympia, WA 98504-7877

Contact us:
360-236-4700

DOH 690-134 March 2017


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Application Instructions Checklist
Important background check Information: Washington State law authorizes the
Department of Health to obtain fingerprint-based background checks for licensing
purposes. This check may be through the Washington State Patrol and the Federal
Bureau of Investigation (FBI). This may be required if you have lived in another state or
if you have a criminal record in Washington State. This would be at your own expense.
All information should be printed clearly in blue or black ink. It is your responsibility to
submit the required forms.
FF Application Fee. This fee is non-refundable. You can check the online fee page
for current fees.
FF Select if the following applies:
Spouse or Registered Domestic Partner of Military Personnel
FF 1. Demographic Information:
Social Security Number: You must list your social security number on your
application. Please call the Customer Service Center at 360-236-4700 if you do not
have one.
National Provider Identifier Number (NPI): The National Provider Identifier (NPI)
is a standard unique identifier for health care professionals available from the
Federal Centers for Medicare and Medicaid Services. The NPI is a 10 digit numeric
identifier. If you have a NPI number, provide this on your application.
Legal Name: List your full name: first, middle, and last.
Definition of legal name: “Legal name” is the name appearing on your official
certificate of birth or, if your name has changed since birth, on an official marriage
certificate or an order by a court. The court must have the legal authority to change
your name. We may ask you to prove your legal name. If you use any name other
than your legal name on this form, your application may be denied.
Birth date: Provide the month, day, and year of your birth.
Birth place: Provide the city, state, and country where you were born.
Address: List the address we should use to send you any information about your
license. Be sure to include the city, state, zip code, county, and country. This will be
your permanent address with the Department of Health until we have been notified
of a change. See WAC 246-12-310.
Phone, Fax and Cell Numbers: Enter your phone, fax and cell numbers, if you
have them.
Email: Enter your email address, if you have one. To expedite notice to the
applicant, we will use the email address as the primary contact source to update
the applicant on the status of their application. It is important to ensure the email
address is correct and current at all times.
Other Name(s): Indicate whether you are known or have been known by any other
names. If you have a name change, you must notify the Department of Health in
writing. You must include legal proof of this change. See WAC 246-12-300.
FF 2. Personal Data Questions:
All applicants must answer the same personal data questions. They are focused on
DOH 690-232 March 2017 Page 1 of 2
your fitness to practice the essential skills of this profession.
If you answer “yes” to any questions in this section, you must provide a complete
and accurate explanation. You must also submit appropriate documentation as
noted in the personal data questions. If you do not provide this, your application is
incomplete and it will not be considered.
• Question 5 includes misdemeanors, gross misdemeanors and felonies. You do
not have to answer yes if you have been cited for traffic infractions. You can get
copies of court records through the county courthouse where the conviction,
plea, deferred sentence, or suspended sentence was entered.
• If you have been granted certificate(s) of restoration of opportunity, please
provide a certified copy of each certificate.
• Another jurisdiction means any other country, state, federal territory, or military
authority.
FF 3. Other Licensure, Certification, or Registration:
List all states, including Washington, where credentials are or were held. Attach
additional completed pages if you need more space. You must also print the
Verification Form and provide it to each state or jurisdiction that you have listed,
requesting that they complete and submit the form directly to the Department of
Health.
FF 4. Education and Training:
List in date order, most recent to later, all your educational preparation and post-
graduate training. Attach additional completed pages if you need more space.
FF 5. Experience:
List in date order, most recent to later, all your professional work experience. Attach
additional completed pages if you need more space.
FF 6. AIDS Education and Training Attestation:
Read the AIDS education and training attestation. AIDS training may include self-
study, direct patient care, courses, or formal training. A minimum of seven hours
is required. Course content can be found in WAC 246-12-270. If AIDS education
was included in your professional education or training, an additional course is not
required.
FF 7. Applicant’s Attestation:
You must sign and date this for us to process the application.
For Spouses and Registered Domestic Partners of Military
Personnel Being Transferred or Stationed in Washington:
Under state law, if you are the spouse or state-registered domestic partner of a
servicemember of any branch of the U.S. Military, to include Guard or Reserve, and
are applying for a health care professional credential in this state, you may be eligible
to have the processing of your application expedited to receive your credential more
quickly.
Documents to submit with your application should include the following:
• A copy of your spouse’s or registered domestic partner’s military transfer orders
to Washington State.
• One of the following:
-- A copy of your marriage certificate to show proof of marriage; or
-- A copy of a state’s declaration or registration showing you are in a state
registered domestic partnership with a member of the U.S. military.
DOH 690-232 March 2017 Page 2 of 2
License Requirements

This is information to apply for a pharmacist license by examination for (U.S. graduates-
original license by exam). For more information visit our website.
General Information
1. You must be a graduate of an accredited United States pharmacy school or college.
2. Washington State uses the North American Pharmacist License Exam (NAPLEX)
to test your knowledge, judgment and skills as an entry-level pharmacist. Multistate
Pharmacy Jurisprudence Examination (MPJE) tests you on both federal, state laws
and rules.
3. The Pre-NAPLEX practice examination is available on the National Association of
Boards of Pharmacy (NABP) website at https://nabp.pharmacy/.
4. You must submit a computerized exam registration form for both the NAPLEX and
MPJE at https://nabp.pharmacy/ or mail it to 1600 Feehanville, MT. Prospect
IL 60056. You may complete the registration forms and submit the payment by
credit card, VISA or Master Card, at the NABP Website. If you do not have a credit
card and prefer not to register online, you can get the paper registration forms by
sending a request with your name and address to our Customer Service Office at
hsqa.csc@doh.wa.gov, or by calling 360-236-4700.
5. To receive your Authorization to Test (ATT):
• Register with and pay exam fees to the NABP.
• Submit all items required before testing to our office.
Once the above steps have been completed, WA Pharmacy Quality Assurance
Commission will then release your name to the NABP as “ready to test”. The
NABP will send your ATT.
• We will notify you of your test results. Contact Office of Customer Service at
360-236-4700 if you have questions about licensure in Washington State.
6. Reporting intern hours: The commission accepts internship hours completed
as part of an ACPE accredited college/school of pharmacy, when reported
directly from the college/school of pharmacy or certifying state Pharmacy Quality
Assurance Commission.
Washington students must earn 300 internship hours independent from the
accredited college/school of pharmacy curriculum. Qualifying internship hours
are earned under the personal supervision of a preceptor or licensed pharmacist,
in a licensed pharmacy in the United States. The pharmacist’s license and
preceptor certification (if applicable) is active and in good standing. Use the
Preceptor Evaluation and Certification of Experience and Intern Site Evaluation
forms to report these hours to the Washington State Pharmacy Quality Assurance
Commission for each location.

DOH 690-135 March 2017


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Pharmacy Quality Assurance
Commission Credentialing
PO Box 47877
Olympia, WA 98504-7877
360-236-4700

Requirements Checklist
This is information to apply for a Pharmacist License by Examination for (U.S. Graduates-
Original License by Exam)

Note: Use this checklist as a tool to track information as you send items to the commission.

Name _______________________________________________________________________

Address _____________________________________________________________________

City ____________________________________ State ___________ Zip Code ____________

Items required before Intern Registration:


__________ State intern application with the non refundable application fee.
See online fee page.
__________ Letter from accredited pharmacy school verifying admittance.

Items required before taking NAPLEX and MPJE:


__________ State pharmacist application with the nonrefundable fee. See online fee page.

__________ Proof of your graduation.

Required before pharmacist license:


__________ Preceptor Evaluation (Washington State students only).

__________ Intern Site Evaluation Report (Washington State students only).

__________ Certification of a total of 1500 intern hours, we have received ____________.

__________ 7 hours of AIDS education.

__________ NAPLEX score, on_____________________ you received a score of _________.



__________ MPJE score, on _______________________ you received a score of _________.
__________ Official transcript sent directly from your pharmacy school.

DOH 690-136 March 2017


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Date
Stamp
Here
Revenue: 0262010000
Pharmacist License Application
Please check the appropriate box:
c By Exam (NAPLEX) for U.S. Graduates Licensed c By Exam (NAPLEX) for New Graduates
only in FL or CA c By Score Transfer for U.S. Graduates
c By Exam (NAPLEX) for Foreign Graduates c By Score Transfer for Foreign Graduates
c By License Transfer/Reciprocity for Foreign Graduates c By License Transfer/Reciprocity for U.S. Graduates
c By Score Transfer - U.S. Graduates c By Exam (NAPLEX) for - Foreign Graduates
Licensed only in FL or CA Licensed FL or CA
Select if the following applies: c Spouse or Registered Domestic Partner of Military Personnel
1. Demographic Information
Social Security Number (SSN) National Provider Identifier Number (NPI)
(If you do not have a SSN, see instructions) (Enter 10 digit number)  Male
 Female

Name First Middle Last

Birth date (mm/dd/yyyy) Place of birth


City State Country

Address

City State Zip Code County

Country

Phone (enter 10 digit #) Fax (enter 10 digit #) Cell (enter 10 digit #)

Email address:

Mailing address if different from above address of record

City State Zip Code County

Country

Note: The mailing and email addresses you provide will be your addresses of record. It is your
responsibility to maintain current contact information on file with the department.
Have you ever been known under any other name(s)?  Yes  No
If yes, list name(s):
Will documents be received in another name?  Yes  No
If yes, list name(s):
DOH 690-233 March 2017 Page 1 of 5
2. Personal Data Questions Yes No
1. Do you have a medical condition which in any way impairs or limits your ability to practice your
profession with reasonable skill and safety? If yes, please attach explanation......................................... 
“Medical Condition” includes physiological, mental or psychological conditions or
disorders, such as, but not limited to orthopedic, visual, speech, and hearing impairments,
cerebral palsy, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease, diabetes,
intellectual disabilities, emotional or mental illness, specific learning disabilities, HIV disease,
tuberculosis, drug addiction, and alcoholism.
If you answered yes to question 1, explain:
1a. How your treatment has reduced or eliminated the limitations caused by your medical condition.
1b. How your field of practice, the setting or manner of practice has reduced or eliminated the
limitations caused by your medical condition.
Note: If you answered “yes” to question 1, the licensing authority will assess the nature,
severity, and the duration of the risks associated with the ongoing medical condition
and the ongoing treatment to determine whether your license should be restricted,
conditions imposed, or no license issued.
The licensing authority may require you to undergo one or more mental, physical or
psychological examination(s). This would be at your own expense. By submitting this
application, you give consent to such an examination(s). You also agree the
examination report(s) may be provided to the licensing authority. You waive all claims
based on confidentiality or privileged communication. If you do not submit to a
required examination(s) or provide the report(s) to the licensing authority, your
application may be denied.
2. Do you currently use chemical substance(s) in any way which impair or limit your ability to
practice your profession with reasonable skill and safety? If yes, please explain..................................... 
“Currently” means within the past two years.
“Chemical substances” include alcohol, drugs, or medications, whether taken legally or illegally.
3. Have you ever been diagnosed with, or treated for, pedophilia, exhibitionism, voyeurism or
frotteurism?................................................................................................................................................ 
4. Are you currently engaged in the illegal use of controlled substances?.................................................... 
“Currently” means within the past two years.
Illegal use of controlled substances is the use of controlled substances (e.g., heroin, cocaine)
not obtained legally or taken according to the directions of a licensed health care practitioner.
Note: If you answer “yes” to any of the remaining questions, provide an explanation and
certified copies of all judgments, decisions, orders, agreements and surrenders. The
department does criminal background checks on all applicants.
5. Have you ever been convicted, entered a plea of guilty, no contest, or a similar plea, or had
prosecution or a sentence deferred or suspended as an adult or juvenile in any state or jurisdiction?.... 

Note: If you answered “yes” to question 5, you must send certified copies of all court
documents related to your criminal history with your application. If you do not
provide the documents, your application is incomplete and will not be considered.
If you have been granted certificate(s) of restoration of opportunity, please
provide a certified copy of each certificate.
To protect the public, the department considers criminal history. A criminal history
may not automatically bar you from obtaining a credential. However, failure to report
criminal history may result in extra cost to you and the application may be delayed
or denied.

DOH 690-233 March 2017 Page 2 of 5


2. Personal Data Questions (cont.) Yes No
6. Have you ever been found in any civil, administrative or criminal proceeding to have:
a. Possessed, used, prescribed for use, or distributed controlled substances or legend
drugs in any way other than for legitimate or therapeutic purposes?.................................................... 
b. Diverted controlled substances or legend drugs?................................................................................. 
c. Violated any drug law?.......................................................................................................................... 
d. Prescribed controlled substances for yourself?..................................................................................... 
7. Have you ever been found in any proceeding to have violated any state or federal law or rule
regulating the practice of a health care profession? If “yes”, please attach an explanation and
provide copies of all judgments, decisions, and agreements? ................................................................. 
8. Have you ever had any license, certificate, registration or other privilege to practice a health care
profession denied, revoked, suspended, or restricted by a state, federal, or foreign authority?............... 
9. Have you ever surrendered a credential like those listed in number 8, in connection with or to
avoid action by a state, federal, or foreign authority?................................................................................ 
10. Have you ever been named in any civil suit or suffered any civil judgment for incompetence,
negligence, or malpractice in connection with the practice of a health care profession?.......................... 
11. Have you ever been disqualified from working with vulnerable persons by the Department
of Social and Health Services (DSHS)?...................................................................................................  

3. Other License, Certification, or Registration


List all states, including Washington, where credentials are or were held. Attach additional completed pages if you
need more space.
State/ License/Certification/Registration Method Licensed License/Certification/Registration
Jurisdiction Type Exam Endorse Grandfathered Year issued Number

DOH 690-233 March 2017 Page 3 of 5


4. Education and Training
List in date order, most recent to later, all your educational preparation and post-graduate training. Attach additional
completed pages if you need more space.
Graduate School Degree and Major start (mm/yyyy) end (mm/yyyy)

5. Professional Experience
List in date order, most recent to later, all your professional experience. Attach additional completed pages if you
need more space.
Name and location of institution Type of experience start (mm/yyyy) end (mm/yyyy)

6. AIDS Education and Training Attestation


I certify I have completed the minimum of seven hours of education in the prevention, transmission
and treatment of AIDS. This includes the topics of etiology and epidemiology, testing and counseling,
infection control guidelines, clinical manifestations and treatment, legal and ethical issues to include
confidentiality, and psychosocial issues to include special population considerations.
I understand I must maintain records documenting said education for two years and be prepared
to submit those records to the department if requested. I understand I should provide any false
information, my license may be denied, or if issued, suspended or revoked. If AIDS education was
included in your professional education or training, an additional course
Applicant’s Initials Today’s Date
is not required.

DOH 690-233 March 2017 Page 4 of 5


7. Applicant’s Attestation

I, _________________________________________ , declare under penalty of perjury under the laws of


(Name of applicant)
the state of Washington that the following is true and correct:

• I am the person described and identified in this application.


• I have read RCW 18.130.170 and RCW 18.130.180 of the Uniform Disciplinary Act.
• I have answered all questions truthfully and completely.
• The documentation provided in support of my application is accurate to the best of my knowledge.
• I have read all laws and rules related to my profession.
I understand the Department of Health may require more information before deciding on my application.
The department may independently check conviction records with state or federal databases.
I authorize the release of any files or records the department requires to process this application. This
includes information from all hospitals, educational or other organizations, my references, and past and
present employers and business and professional associates. It also includes information from federal,
state, local, or foreign government agencies.
I understand I must inform the department of any past, current or future criminal charges or
convictions. I will also inform the department of any physical or mental conditions that jeopardize my ability
to provide quality health care. If requested, I will authorize my health providers to release to the
department information on my health, including mental health and any substance abuse treatment.

Dated___________________________________ By:________________________________________
(mm/dd/yyyy) (Original signature of applicant)

DOH 690-233 March 2017 Page 5 of 5


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Pharmacy Quality Assurance
Commission Credentialing
PO Box 47877
Olympia, WA 98504-7877
360-236-4700
Intern Site Evaluation Report
Note: This form must be submitted to the Commission office upon completion of an internship
experience. No internship hours will be accepted without this evaluation report pursuant to
WAC 246-858-050(1). If the internship experience exceeds twelve months, it is recommended that
this form be submitted annually.

Name of Intern: Credential #

Name of Preceptor:

Preceptor Certificate Number:

Preceptor Location Address:

Preceptor License Number:

Name of Internship Site:

Intern evaluation of preceptor:

Intern evaluation of internship program at this site:

Signature of Intern Date:

DOH 690-054 March 2017


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Pharmacy Quality Assurance
Commission Credentialing
PO Box 47877
Olympia, WA 98504-7877
360-236-4700
Preceptor Evaluation & Certification of Experience
This form must be submitted to the commission at the completion of the internship experience. If the internship
experience exceeds twelve months, it is recommended that this form be filed annually.
Name of Intern

Year In School Credential #


1 2 3 4
Intern Street address

City State Zip Code

Name of Preceptor

Name of Internship Site

Street Address

City State Zip Code

Preceptor Evaluation of Intern


Briefly describe the type of professional experience received under your supervision. Comment on the intern’s
communication skills, accuracy, professional attitude, dispensing skills, ability to evaluate and monitor therapy,
and knowledge of pharmacy management. Also, pursuant to WAC 246-858-070(3), provide your assessment of
the intern’s ability to practice pharmacy at this stage of his or her internship. Attach additional completes pages if
you need more space.

Signature of Preceptor Date

DOH 690-095 March 2017 Page 1 of 2


For the Two-Week Period of For the Two-Week Period of
From (Sunday) To (Saturday) Hours From (Sunday) To (Saturday) Hours

Total internship hours________________________

Note: Internship hours will not be accepted after the signature date.

Preceptor Certification of Experience

I,__________________________________________________________ certify I am a pharmacist licensed in the

State of ___________________________________. The above named intern practiced pharmacy under my

supervision at _______________________________________________ pharmacy, or under a special internship


program. I certify the intern has completed goals set forth in the Washington State Pharmacy Quality Assurance
Commission Experiential Training Manual. The hours here recorded are correct, and to the best of my knowledge,
the experience gained by the intern has been related to the practice of pharmacy as required by law.

________________________________________ __________________ ___________________________


Preceptor’s signature Date License number

DOH 690-095 March 2017 Page 2 of 2


RCW/WAC and Online Website Links

RCW/WAC Links
Uniform Disciplinary Act, RCW 18.130
Administrative Procedure Act, RCW 34.05
Administrative Procedures and Requirements, WAC 246-12
Pharmacy Laws, RCW 18.64
Pharmacy Rules, WAC 246-863

Online
AIDS Training Resources, Reference Page
Pharmacy Quality Assurance Commission, Web Page

RCW/WAC and Online Website Links March 2017

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