1. (a) Registered pharmacy technician applicants shall complete and submit an “Initial Application for Pharmacy Technician Registration” form (PT-1), or electronic equivalent, for registration to the board that contains the following:

   1. (1) Legal name, residence address, mailing address, home or cell phone number, personal e-mail address, and social security number of the applicant;
   2. (2) Date and place of birth and gender of the applicant;
   3. (3) Name of current employer and the mailing address, phone number, and e-mail address of employment site;
   4. (4) Name of supervisor and pharmacy phone number;
   5. (5) An indication as to whether or not the applicant has been convicted of a drug or pharmacy-related felony or misdemeanor or admitted to sufficient facts to warrant such a finding, and if yes, an explanation, an explanation of the circumstances surrounding such a finding or conviction;
   6. (6) An indication as to whether the applicant has ever voluntarily surrendered for disciplinary reasons a license, registration, or certification to practice as a pharmacy technician in any jurisdiction and, if so, an explanation of such surrender;
   7. (7) An indication as to whether the applicant has any felony convictions and, if so, an explanation of such convictions; and
   8. (8) Applicant's signature and date.
2. (b) The prescribed fee shall be $100, and shall be submitted with the completed application form.
3. (c) The “Initial Application for Pharmacy Technician Registration” form PT-1 for registration of pharmacy technicians in New Hampshire may be obtained from and shall be filed at the office of the board, identified in Ph 103.03.

Source. #12671, eff 11-17-18