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***We are no longer accepting applications.
2024-2025 AMDPA PSIP Online Application Submission
First Name
Last Name
Birthday (MM / DD / YYYY) *Must be 18 Years of age or older*
Sex
Female
Male
Race/Ethnicity (Check All That Apply)
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
What county are you from?
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?
High School Graduate
GED Recipient
College Undergraduate 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?
Yes
No
Why are you interested in the program?
List your achievements, volunteer work, and 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?
Yes
No
Are You Able To Commute 20-30 Miles To The Assigned Pharmacy?
Yes
No
Have You Ever Been Convicted Of A Crime?
Yes
No
If So, List Conviction & Date (Criminal Background Check Is Required).
I certify that all informaton provided is accurate.
Today's Date
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