PGY-1 Pharmacy Practice Residency Application Form
Instructions: Please complete Sections A through D. Please type.
Section A: Personal Information
Last Name
First Name
Permanent Address
Street
City
State
School Address
Street
City
State
Preferred Phone Number
Middle Name or Initial
Zip code
Zip code
Preferred Email Address
ASHP Match Number (if known)
Section B: References
Name
Title
Email
Phone
Name
Title
Email
Phone
Name
Title
Email
Phone
Department of Pharmacy Services
555 North Duke Street
Lancaster, PA 17604
717-544-5219
aprusch2@LGHealth.org
Section C: Pharmacy Internship
Do you currently have a pharmacy intern license in Pennsylvania?
Yes
No
If yes (*750 hours non-school intern hours is the minimum for PA):
 How many non-school intern hours have you officially logged with the PA State Board of
Pharmacy? _________hrs

How many non-school intern hours do you still have to officially log with the PA State
Board of Pharmacy? _________hrs
If no:
 Have you [or are you planning in the near future] officially logged pharmacy intern hours
with another State Board of Pharmacy? (*750 hours non-school intern hours is the minimum for
PA)
Yes
No

Have you logged at least 750 non-school internship hours (e.g. work experience)?
Yes
No

Please name the state(s): _________________________________________________
Section D: Applicant Questions (please type – may extend onto 3rd page)
1. In addition to your letter of intent/CV, please describe why Lancaster General Health has
the potential to be a good match for you as a PGY-1 resident.
2. In your own words and based on your personal experience to date, briefly describe how you
envision the profession of pharmacy progressing over the next 5-10 years. [There is no
wrong answer.]
Applicant Signature: ________________________________
Date: __________________
*The Pennsylvania State Board of Pharmacy requires that pharmacy interns log 1500 internship hours for licensure. 750 intern hours will be
accepted from a school of pharmacy’s internship program. The remaining 750 hours must be obtained from non-school internship hours (e.g. work
experience). Please contact the Pennsylvania State Board of Pharmacy for questions pertaining to Pennsylvania state licensure.
Department of Pharmacy Services
555 North Duke Street
Lancaster, PA 17604
717-544-5219
aprusch2@LGHealth.org