Updated 02/2017lh PHARMACY TECHNICIAN PROGRAM APPLICATION PROCESS Applying for FALL 2017 admission for: ______Certificate ______Associates of Applied Science 1. Apply to the College of the Mainland (COM) at http://www.com.edu/apply/ and meet all general admission requirements. Admission to the College of the Mainland DOES NOT guarantee admission into the Pharmacy Technician Program. 2. Complete and submit the Pharmacy Technician Program application, providing required documentation, to the Administrative Assistants at the Public Service Careers (PSC) Building, 1205 Amburn Rd., Texas City, TX 77591 REQUIRED DOCUMENTATION: A. Documentation of a high school diploma or high school equivalency certificate. You must have a high school diploma or high school equivalency certificate to sit for the national Pharmacy Technician Certification Exam. B. A Pharmacy Technician Required Immunizations and Tests Form completely filled out and copies of Immunization records showing required immunizations. (Blank forms will not be accepted.) Measles, Mumps, and Rubella (MMR): If previously vaccinated and shot records are lost or unavailable, you may validate immunity with a titer level. Hepatitis B (Hep B): proof of 3 doses or a signed Hepatitis B Vaccine Waiver http://www.com.edu/academics/pharmacy-technician/how-to-begin . If previously vaccinated and shot records are lost or unavailable, you may validate immunity with a titer level. Varicella (chickenpox): proof of immunization or signed Documenting History of Illness: Varicella (Chickenpox) form validating disease history by a parent or physician http://www.com.edu/academics/pharmacy-technician/how-to-begin. If previously vaccinated and shot records are lost or unavailable, you may validate immunity with a titer level. Tetanus-Diptheria (Tdap): Must be within the past 10 years. TB skin test (PPD): Must be within 12 months of the externship in Spring semester. Obtain during the Fall Semester once admitted in program. If have had a positive TB skin test, you must have a chest x-ray performed. Influenza (Flu) vaccine: Must be within 12 months of externship in Spring semester. Obtain in the Fall Semester once admitted in program. C. Copy of current Driver’s License or government-issued photo ID. D. Copy of social security card. 3. Selection is based on the date that a completed application is received in the Public Service Careers Building (first come-first serve until filled). First priority is given to QUALIFIED applicants who have met the deadline above. Applications will be continue to be accepted until the class is full . You will be contacted for an interview with the Pharmacy Technician Program upon receipt of your application. If selected for the program, you will be directed to complete a drug screen and criminal background check prior to being fully Completed application must be turned in to the Public Service Careers (PSC) Building prior to registering for pharmacy technician classes. Application Deadline is July 31, 2017. First priority is given to QUALIFIED applicants who have met the above deadline. Applications will be continue to be accepted until the class is full on a first come first serve basis. Students may not register for classes until the application packet is approved, the student has been interviewed by the Pharmacy Technician Program Director, and a background check and drug screens have been completed.
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Updated 02/2017lh
PHARMACY TECHNICIAN PROGRAM APPLICATION PROCESS
Applying for FALL 2017 admission for: ______Certificate ______Associates of Applied Science
1. Apply to the College of the Mainland (COM) at http://www.com.edu/apply/ and meet all general admission
requirements. Admission to the College of the Mainland DOES NOT guarantee admission into the Pharmacy Technician
Program.
2. Complete and submit the Pharmacy Technician Program application, providing required documentation, to the
Administrative Assistants at the Public Service Careers (PSC) Building, 1205 Amburn Rd., Texas City, TX 77591
REQUIRED DOCUMENTATION:
A. Documentation of a high school diploma or high school equivalency certificate. You must have a high school
diploma or high school equivalency certificate to sit for the national Pharmacy Technician Certification Exam.
B. A Pharmacy Technician Required Immunizations and Tests Form completely filled out and copies of
Immunization records showing required immunizations. (Blank forms will not be accepted.)
Measles, Mumps, and Rubella (MMR): If previously vaccinated and shot records are lost or
unavailable, you may validate immunity with a titer level.
Hepatitis B (Hep B): proof of 3 doses or a signed Hepatitis B Vaccine Waiver
http://www.com.edu/academics/pharmacy-technician/how-to-begin . If previously vaccinated
and shot records are lost or unavailable, you may validate immunity with a titer level.
Varicella (chickenpox): proof of immunization or signed Documenting History of Illness: Varicella
(Chickenpox) form validating disease history by a parent or physician
http://www.com.edu/academics/pharmacy-technician/how-to-begin. If previously vaccinated
and shot records are lost or unavailable, you may validate immunity with a titer level.
Tetanus-Diptheria (Tdap): Must be within the past 10 years.
TB skin test (PPD): Must be within 12 months of the externship in Spring semester. Obtain during
the Fall Semester once admitted in program. If have had a positive TB skin test, you must have
a chest x-ray performed.
Influenza (Flu) vaccine: Must be within 12 months of externship in Spring semester. Obtain in the
Fall Semester once admitted in program.
C. Copy of current Driver’s License or government-issued photo ID.
D. Copy of social security card.
3. Selection is based on the date that a completed application is received in the Public Service Careers Building
(first come-first serve until filled). First priority is given to QUALIFIED applicants who have met the deadline
above. Applications will be continue to be accepted until the class is full. You will be contacted for an
interview with the Pharmacy Technician Program upon receipt of your application. If selected for the
program, you will be directed to complete a drug screen and criminal background check prior to being fully
Completed application must be turned in to the Public Service Careers (PSC) Building prior to registering for pharmacy
technician classes. Application Deadline is July 31, 2017. First priority is given to QUALIFIED applicants who have met the
above deadline. Applications will be continue to be accepted until the class is full on a first come first serve basis. Students
may not register for classes until the application packet is approved, the student has been interviewed by the Pharmacy
Technician Program Director, and a background check and drug screens have been completed.
accepted. Results of the background check and drug screen will be sent directly to the Pharmacy Technician
Program. Results will be accepted for the duration of the student’s enrollment in the Pharmacy Technician
Program as long as the student does not experience a break in enrollment or any disqualifying allegations or
convictions while enrolled.
4. Upon receipt of satisfactory results from the background check and drug screens, the student will be
admitted into the Pharmacy Technician Program and will be given the paperwork necessary to register for
classes.
5. If a student has not accepted a position in the program within 1 year of the application date, a new
application will be required.
Updated 02/2017lh
PHARMACY TECHNICIAN PROGRAM APPLICATION Applying for FALL 2017 admission for: ___Certificate __Associates of Applied Science
Please PRINT or TYPE Application Date: _____________________ Full Name: ______________________________________________________________________________________ Last First Middle
Home Address: _____________________________________________________________________________________ Physical Address City State Zip
Home Number: _____________________________________ Cell Number: ____________________________________
Social Security Number: ______________________________ Date of Birth: __________________________________ Student ID #: ____________________________ TSBP Technician Trainee Registration Number*__________________ Emergency Contact: ________________________________________________________________________________ Name Phone Number Relationship
Required Documentation (to be photocopied and attached): ______ Documentation of a High School diploma or high school equivalency certificate ______ Completed Pharmacy Technician-Required Immunizations and Tests Form (completely filled out) and copies of
required Immunization Records.
______ Copy of Social Security Card ______Copy of Driver’s License of State-Issued Identification Card
PLEASE NOTE: To be compliant with clinical facility requirements, a background check, drug screen, and
documentation of immunizations will be required prior to admission into the Pharmacy Technician Program. A
criminal background may prevent the issuance of a Texas State Board of Pharmacy Technician Trainee Registration,
which is required for the clinical externship portion of the pharmacy technician program. Illegal or illicit drug use
and criminal backgrounds may prevent licensure, the ability to complete the required internship, and/or future
employment as a pharmacy technician, as employers and State Boards of Pharmacy have regulations concerning
both.
_____ Receipt of Criminal Background History (DO NOT COMPLETE UNTIL DIRECTED TO DO SO)
______ Receipt of 10-Panel Drug Screen (DO NOT COMPLETE UNTIL DIRECTED TO DO SO)
Updated 02/2017lh
Pharmacy Technician Required Immunizations and Tests Form
Name: COM ID#:
Date of Birth: _______________________
Measles/Mumps/Rubella:* must show proof of:
A. Dose of measles/mumps/rubella vaccine
OR
Date
(mm/dd/yy)
B. Serologic test (titer) positive for
measles/mumps/rubella antibody
Date Result
(mm/dd/yy)
Hepatitis B * must show proof of:
A. The minimum interval between the first two
doses is 4 weeks, and the minimum
interval between the second and third
doses is 8 weeks. However, the first and
third doses should be separated by no less
than 16 weeks. It is not necessary to restart
the series or add doses because of an
extended interval between doses.
OR
Date #1
(mm/dd/yy)
Date #2
(mm/dd/yy)
Date #3
(mm/dd/yy)
B. Serologic test (titer) positive for Hepatitis B
antibody
OR
Date: Result
(mm/dd/yy)
C. Signed Hepatitis B Vaccine Waiver
**See note.
Date:_______________________
Updated 02/2017lh
Varicella* must show proof of:
A. One dose of varicella vaccine OR
Date
(mm/dd/yy)
B. Serologic test positive for Varicella antibody
OR
Date Results
(mm/dd/yy)
C. Parent or Physician Signed Documented
History or Illness: Varicella (Chicken
Pox)
**See note.
Date Disease Occurred
(mm/dd/yy)
Tdap* must show proof of:
One dose of Tdap vaccination
Note: After Tdap, TD booster every 10 years.
Date
(mm/dd/yy)
**Do Not Obtain PPD and Influenza Immunizations until Admitted into Program**
PPD (Tuberculosis)*** must show proof of:
One negative test screening within 12 months of
Internship (Internships are Jan through June—2nd semester)** Date ________________________________________
(mm/dd/yy)
Influenza (Seasonal Flu)*** must show proof of:
One dose within 12 months of internship
(Internships are January through June—2nd semester)** Date ________________________________________
(mm/dd/yy)
*Copies of Proof of immunizations must be included with this completed form with appropriate physician signatures.
**Hepatitis B Vaccine Waiver and Documenting History of Illness (Varicella) Forms may be found on the College of the