:: Initial Applications ::

INTERN INITIAL REGISTRATION INSTRUCTIONS

Intern registration can initially be applied for after completing one week of classes at an accredited college of pharmacy.

For application information and instructions, please go to this link: https://doh.sd.gov/licensing-and-records/boards/pharmacy/licensing-requirements/pharmacy-interns/ .

INTERN INFORMATION

First Name

Middle Name

Last Name

Maiden Name

Mailing Address

Address1

Address2

Address3

Zip

City

State

County

Date of Birth

Social Security Number

Primary Number

Alternate Number

Gender

Male

Female

Name of College of Pharmacy

Current Photo

PROFESSIONAL YEAR

Please select your current year (select one)

Anticipated Year of Graduation

NABP e-profile ID

AFFIRMATION

Complete the Certification of Eligibility for Doctor of Pharmacy Candidates form. Your faculty representative at the accredited college of pharmacy you attend needs to sign, date, and properly completed all information.

APPLICATION INPUT PREVIEW

AFFIRM AND SUBMIT

I, the undersigned, do hereby apply to the South Dakota State Board of Pharmacy for registration as a Pharmacy Intern, as provided in the rules of the South Dakota State Board of Pharmacy.

I understand that as a Registered Pharmacy Intern I may not perform any of the duties required of a registered pharmacist except when I am working under the continuous and personal supervision of a registered pharmacist and that my duties may not exceed those in guidelines provided by the Board.

I also understand that should I perform any duties which I am not licensed to perform, or which exceed my educational level or if I falsely assume to be a pharmacist, or engage in any activity considered to be unprofessional conduct, I am placing my privilege of becoming a licensed pharmacist in South Dakota in jeopardy.

I further understand that I must submit records of my internship experience on forms provided by or prescribed by the Board and that credit for internship experience will not be granted unless registration and forms describing internship experience are completed and submitted to the Board in a timely manner.

I also understand that I am required to notify the Board within 10 days of a name or address change while I am registered as an Intern. Complete a change form found at this link: http://doh.sd.gov/boards/pharmacy/intern.aspx

I agree to abide by the South Dakota pharmacy law and the rules of the Board of Pharmacy. I declare and affirm under the penalties of perjury that this application has been completed by me, electronically signed by me, and to the best of my knowledge and belief, is in all things true and correct.

E-Signature

Date

License Fee

Select Debit or Credit

Card Type

Person’s Name on Card

Card #

Expiration Date (MM/YY)

Security code (3-digit number or 4-digit number if American Express/Amex)

All application fees are nonrefundable and nontransferable.

P1	P2
P3	P4	FPEGC

Intern Initial / New Application