:: Initial Applications ::

TECHNICIAN INSTRUCTIONS

You must:
1. Be currently employed as a pharmacy technician in South Dakota pharmacy at the time of application and
2. Be 16 years of age or older

A “certified” technician must provide a copy of their current certification certificate.

Do not use this application if you have ever been issued a South Dakota technician registration.

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

All application fees are nonrefundable and nontransferable.

TECHNICIAN 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 Phone Number

Alternate Phone Number

Gender

Male

Female

NABP e-profile ID

^*I am currently a certified technician.

Yes

CERTIFICATION INFORMATION

Certifying Agency Name

PTCB

ExCPT

Certificate Original Issue Date

Certificate Number

Certificate Current Expiration Date

PTCB or ExCPT Certification Certificate

WORK HISTORY

Employed at current employer(s) for last five years

Has not worked in past 5 years

List work experience with other employers for the last five years

RECORD OF DISCIPLINE, CHARGES, AND CONVICTIONS

*Declaration of current impairment or limitations (ARSD 20:51:29:08)

1. In the past 5 years, have you ever been counseled, reprimanded, or terminated from a job because of the use of any drugs, alcohol, or other chemical substances?

Yes

*Felony or misdemeanor crimes (ARSD 20:51:29:09)

2. Within the past 5 years, have you ever been charged, convicted, found guilty of, or entered a plea of guilty or no contest to a felony or misdemeanor crime (other than minor traffic violations with fines under $100)?

Yes

*Disciplinary Action

3. Have you ever been disciplined or are there pending disciplinary actions against you or a registration or license by any licensing board?

Yes

APPLICATION INPUT PREVIEW

AFFIRM AND SUBMIT

I agree to abide by the laws and rules related to the Practice of Pharmacy in South Dakota. 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 of the person filling out this renewal

Date

License Fee

Debit /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.

Business/Company Name

Business/Company Address

Address1

Address2

Address3

Zip Code

City

State

Job Title

Dates Employed

Technician Initial / New Application