OHIO STATE BOARD OF PHARMACY
77 South High Street, Room 1702; Columbus, OH 43215-6126
-Equal Opportunity Employer and Service Provider-
TEL: 614/466-4143
E-MAIL: exec@bop.state.oh.us
FAX: 614/752-4836
TTY/TDD: Use the Ohio Relay Service: 1-800/750-0750
URL: http://www.pharmacy.ohio.gov
VERIFICATION OF ENROLLMENT
[Type or legibly print all entries. Sign and date the form. Mail the original to the Board office.]
TO THE STATE OF OHIO BOARD OF PHARMACY:
THIS IS TO CERTIFY THAT
,
BEGAN ATTENDING PROFESSIONAL CLASSES IN THE PHARM. D. PROGRAM AT THE
Ohio Northern University, Raabe
COLLEGE OF PHARMACY
(Name of College or University)
ON
, HAS SUCCESSFULLY COMPLETED A MINIMUM OF 60
(mm/dd/yyyy)
SEMESTER HOURS /90 QUARTER HOURS OF COLLEGE WORK, AND IS WORKING TO FULFILL
THE REQUIREMENTS FOR LICENSURE AS A PHARMACIST.
PER THE OHIO ADMINISTRATIVE CODE RULE 4729-3-02(B) (1) (a) AND 4729-3-03(A) (4) THE
ABOVE STUDENT HAS MET THE REQUIREMENTS TO RECEIVE THEIR INTERN LICENSE.
(Signature of College of Pharmacy Dean or Dean’s Designee)
Administrative Assistant
Pharmacy Student Services
(Title)
(Date of Signature)
419-772-2278
(Area Code/Telephone Number)
PHA-0101(Rev.6/2014) Completion of this form required by ORC. Sec. 4729.12. Maximum Penalty: Denial of Intern License