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2025 AMDPA Pharmacy Internship Program Online Application Submission
First Name
Last Name
Birthday (MM / DD / YYYY) *Must be 18 Years of age or older*
Sex
*
Required
Female
Male
Race/Ethnicity (Check All That Apply)
*
Required
American Indian
Alaska Native
Asian American
Black or African American
Hispanic or Latino
Native Hawaiin or Pacific Islander
White
Two or More Races
Physical Address
Physical Address Line 2
City
State
Postal / Zip code
Mailing Address
Mailing Address Line 2
City
State
Postal / Zip code
What county are you from?
Phone Number (Including Area Code)
Email Address
How Did You Hear About The Program?
School Name (If applicable)
What Is Your Current Status?
*
Required
High School Graduate
GED Recipient
College Student
Pharmacy Student
Have You Worked In A Pharmacy Before? If So, List Name Of Pharmacy & Dates Worked.
Did You Participate In AMDPA's Pharmacy Summer Program Last Year?
*
Required
Yes
No
Why are you interested in the program?
List your achievements, volunteer work, and any other information you would like to share.
List Training Or Certificates If Applicable.
Reference #1: First & Last Name
Reference #1: Phone Number
Reference #1: Email Address
Reference #1: Relation to Applicant
Reference #2: First & Last Name
Reference #2: Phone Number
Reference #2: Email Address
Reference #2: Relation to Applicant
Do You Have Access To Transportation?
*
Required
Yes
No
Are You Able To Commute 20-30 Miles To The Assigned Pharmacy?
*
Required
Yes
No
Have You Ever Been Convicted Of A Crime?
*
Required
Yes
No
If So, List Conviction & Date (Criminal Background Check Is Required).
I certify that all informaton provided is accurate.
Today's Date
Submit
Your application has been received. Thanks for submitting!
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