:: 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. Have a high school diploma or GED before you can submit a technician application
      a. Shadow programs may be considered for exemption of a high school diploma or GED

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

Complete a renewal application If you have ever been issued a South Dakota technician registration and do not use the initial application.

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

TYPE OF TECHNICIAN

Have you ever been registered as a pharmacy technician in any state beside South Dakota

Yes

Are you employed as a

Technician-in-Training (TT)

Certified Technician (CPhT)

Enrolled in pharmacy technician degree/diploma granting secondary education program (TT)

EDUCATION

Are you a high school graduate, have the equivalent (GED), or have a previous Board of Pharmacy waiver

Yes	No
Other

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

2. Do you have any physical dependency or mental condition which in any way impairs or limits your ability to perform the duties of a pharmacy technician with reasonable skill and safety?

Yes

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

3. 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

Note: Provide on separate sheet of paper, a signed and dated explanation and attach court records of the charges, convictions, charges found guilty of, or entered a plea of guilty or no contest to.

*Disciplinary Action

4. 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 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 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.

State

Name Of Program Or Job Training Entity

Name of school or training facility BEYOND high school

School/Training Address

Address1

Address2

Address3

Zip

City

State

Date attended from

Date attended to

Field of Study

Degree or Certificate Obtained

Yes

Business/Company Name

Business/Company Address

Address1

Address2

Address3

Zip Code

City

State

Job Title

Dates Employed

Technician Initial / New Application