Pharmacy Technician Program Application

Name*

First Name

Last Name

Social Security Number*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Email*

Phone

Cell Phone*

Date of Birth*

Gender*

Female Male

Race/Ethnicity*

Asian or Pacific Islander Black or African American (Non-Hispanic) Non-Resident Alien Hispanic American Indian or Alaska Native White (Non-Hispanic) Two or more races

Do you have a high school diploma?*

Yes No

Are you currently pursuing a high school diploma?*

Yes No

Do you have a GED?*

Yes No

Are you currently pursuing a GED?*

Yes No

A COMPLETE APPLICATION FOR ADMISSION INTO THE PHARMACY TECHNICIAN PROGRAM MUST INCLUDE:

-Government Issued ID

Class registration is on a first come first serve basis. Classes fill up quickly.

I hereby attest that the information given is accurate and complete to the best of my knowledge. I understand that submission of false or misrepresented information subjects me to refusal of enrollment or dismissal from the program. I acknowledge that the completion of Pharmacy Technician courses will not earn any college credits.

Government Issued Id No File Chosen

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Signature*

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Enterprise State affords equal opportunity to all employees and applicants for admission or employment regardless of race, color, gender, religion, national origin, age or disability. Enterprise State will make reasonable accommodations for persons with disabilities. Questions concerning Title IX or the Americans with Disabilities Act should be directed to Kevin Ammons at 334-347-2623 x2297.