Pharmacy Technician Application Packet
Contents:
1. 690-220 .....Contents List/SSN Information/Mailing Information ........................1 Page
2. 690-151 .....Application Instructions Checklist ................................................. 3 Pages
3. 690-121 .....Licensing Requirements ............................................................... 3 Pages
4. 690-057 .....Pharmacy Technician Application ................................................. 5 Pages
5. 690-215 .....Director Certication (WA Commission approved programs) .........1 Page
6. 690-216 .....Adavit of An Out of State Formal/Academic Technician
Education and Training ................................................................ 2 Pages
7. 690-217 .....Adavit of An Out of State On-the-job Pharmacy Technician
Education and Training ................................................................ 2 Pages
8. 690-104 .....Verication of Current Active Pharmacy Practice ...........................1 Page
9. 690-218 .....Letter of Recommendation .............................................................1 Page
10. 690-102 .....Law Study Verication ....................................................................1 Page
11. RCW/WAC and Online Website Links...............................................................1 Page
Important Social Security Number Information:
If you have a Social Security Number, the law requires you to disclose it on your
application for a professional or occupational license. 42 U.S.C. § 666(a)(13); RCW
26.23.150. It will be used under the state’s child support enforcement program to locate
individuals for purposes of establishing paternity and establishing, modifying, and
enforcing support obligations. You are not required to have or obtain a Social Security
Number to apply for or obtain a license from the Department of Health. If you do not
have a Social Security Number, you are still eligible to apply for and obtain a credential
if you meet the requirements. Please see the Declaration of No Social Security Number
Form. Please call the Customer Service Center at 360-236-4700 if you have questions.
In order to process your request:
Mail your application with initial
documentation and your check Send other documents not sent
or money order payable to: with initial application to:
Department of Health Pharmacy Technician Credentialing
P.O. Box 1099 P.O. Box 47877
Olympia, WA 98507-1099 Olympia, WA 98504-7877
Contact us:
360-236-4700
To request this document in another format, call 1-800-525-0127. Deaf or hard of
hearing customers, please call 711 (Washington Relay) or email civil.rights@doh.
wa.gov.
DOH 690-220 October 2021
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Important background check Information: Washington State law authorizes the
Department of Health to obtain ngerprint-based background checks for licensing
purposes. This check may be through the Washington State Patrol and the Federal
Bureau of Investigation (FBI). This may be required if you have lived in another state or
if you have a criminal record in Washington State. This would be at your own expense.
All information should be printed clearly in blue or black ink. It is your responsibility to
submit the correct required forms.
F Application Fee.
This fee is non-refundable. You can check the online fee page for current fees.
F Check if either apply:
Request for Military Training and Experience Evaluation
Spouse or Registered Domestic Partner of Military Personnel
F 1. Demographic Information:
Social Security Number: You must list your social security number on your
application. You are not required to have or obtain a Social Security Number
to apply for or obtain a license from the Department of Health. Please see the
Declaration of No Social Security Number Form. Please call the Customer Service
Center at 360-236-4700 if you do not have one.
National Provider Identier Number (NPI): The National Provider Identier (NPI)
is a standard unique identier for health care professionals available from the
Federal Centers for Medicare and Medicaid Services. The NPI is a 10 digit numeric
identier. If you have a NPI number, provide this on your application.
Legal Name: List your full name: rst, middle, and last.
Denition of legal name: Legal name is the name appearing on your ocial
certicate of birth or, if your name has changed since birth, on an ocial marriage
certicate or an order by a court. The court must have the legal authority to change
your name. We may ask you to prove your legal name. If you use any name other
than your legal name on this form, your application may be denied.
Birth date: Provide the month, day, and year of your birth.
Address: List the address we should use to send any information about your
license. Be sure to include the city, state, zip code, county, and country. This will be
your permanent address with Department of Health until we have been notied of a
change. See WAC 246-12-310.
Phone, Fax and Cell Numbers: Enter your phone, fax and cell numbers, if you
have them.
Email: Enter your email address, if you have one. To expedite notice to the
applicant, we will use the email address as the primary contact source to update
the applicant on the status of their application. It is important to ensure the email
Application Instructions Checklist
DOH 690-151 October 2021 Page 1 of 3
address is correct and current at all times.
Other Name(s): Indicate whether you are known or have been known under any
other names. If you have a name change, you must notify the Department of Health
in writing. You must include proof of this change. See WAC 246-12-300.
F 2. Personal Data Questions:
All applicants must answer the same personal data questions. They are focused on
your tness to practice the essential skills of this profession.
If you answer “yes” to any questions in this section, you must provide an
appropriate explanation. You must also provide the documentation listed in the note
after the question. If you do not provide this, your application is incomplete and it
will not be considered.
y Question 5 includes misdemeanors, gross misdemeanors and felonies. You do
not have to answer yes if you have been cited for trac infractions. You can get
copies of court records through the county courthouse where the conviction,
plea, deferred sentence, or suspended sentence was entered.
y If you have been granted certicate(s) of restoration of opportunity, please
provide a certied copy of each certicate.
y Another jurisdiction means any other country, state, federal territory, or military
authority.
F 3. Verication of Education and Training:
a. Indicate the process you will use to verify your education and training by
checking the applicable box and attaching required documentation.
b. List all states, including Washington, where credentials are or were held.
Attach additional completed pages if you need more space. You must also
print the Verication Form and provide it to each state or jurisdiction that
you have listed, requesting that they complete and submit the form directly
to the Department of Health.
c. Beginning with the most recent, list by location and type of work/experience
all of your professional experience related to the practice of pharmacy/
pharmacy technician.
F 4. National Certication Exam:
Attach a copy of the certication or proof of passing a pharmacy technician
certication exam administered by a National Commission for Certifying Agencies
(NCCA) accredited organization/program.
F 5. Applicant’s Attestation:
You must sign and date this for us to process your application.
DOH 690-151 October 2021 Page 2 of 3
DOH 690-151 October 2021 Page 3 of 3
For Spouses and Registered Domestic Partners of Military
Personnel Being Transferred or Stationed in Washington:
Under state law, if you are the spouse or state-registered domestic partner of a
servicemember of any branch of the U.S. Military, to include Guard or Reserve, and
are applying for a health care professional credential in this state, you may be eligible
to have the processing of your application expedited to receive your credential more
quickly.
Documents to submit with your application should include the following:
y A copy of your spouse’s or registered domestic partner’s military transfer orders
to Washington State.
y One of the following:
- A copy of your marriage certicate to show proof of marriage; or
- A copy of a state’s declaration or registration showing you are in a state
registered domestic partnership with a member of the U.S. military.
For Current and Former Servicemembers Requesting
Evaluation of Military Training and Experience
Under state law, your military education, training, and experience may count towards
attaining certain civilian health care profession credentials in Washington State.
Submitted information will be reviewed by the Department of Health to determine
substantial equivalency for meeting the credentialing requirements in this state.
Documents to submit with your health care professional credential application should
include the following:
y If applicable, a copy of your DD214 Certicate of Release or Discharge from
Active Duty, Member-4 or service 2 copy, or NGB-22 for National Guard.
Please note:
- A copy of your DD214 can be downloaded from the EBenets website.
- You can request a replacement copy of your NGB-22 on the
National Archives website.
y Ocial Joint Service Transcript (JST) or Community College of the Air
Force(CCAF) Transcripts.
Please note:
- JST can be sent electronically by visiting the JST website and selecting
Washington State Department of Health.
- CCAF transcripts cannot be sent electronically. See the CCAF website for
transcript information.
y Verication of Military Experience and Training (VMET) or DD Form 2586. See
the DoDTAP website.
y If applicable, application for the Evaluation of Learning Experiences During
Military Service (DD Form 295). See the Military Resources website.
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Licensing Requirements
y Completed Application
y Nonrefundable fees
y Verication of Education and Training
y National Certication Examination
y Law Study
National Certication Examination
All applicants must provide verication of successful completion of a commission-
approved program or seek commission approval of training acquired in another state
or country. The Washington Pharmacy Commission requires all applicants to provide
proof of passing a national pharmacy technician certication examination administered
by a program accredited by the National Commission for Certifying Agencies (NCCA).
Information on approved exams can be found by visiting the
Institute for Credentialing Excellence.
Note: National Certication as a pharmacy technician is not a substitute for
commission- approved training or training/education that is considered equivalent
by the Commission.
Applicants who Have Completed Pharmacy Quality Assurance Commission
Approved Pharmacy Technician Program
All training programs must include educational as well as experiential training.
You must submit the following:
y Instructional and Practical/Experiential Training
* Director’s Certication of Pharmacy Technician Education and Training Form
y Legal Aspects of Pharmacy Practice
* Adavit of eight hours Washington State pharmacy law study. The
verication of law study form must be signed by a pharmacist currently
licensed to practice in Washington State.
y Copy of National Certication Examination Certicate or Ocial Score Report.
There are hospitals and retail pharmacies throughout the state with approved programs.
The director of the approved program must complete the director’s certication to verify
successful completion of the on-the-job (OJT) training or formal academic program.
Applicants who Have Completed an Out-of-State Pharmacy Technician Program
Training received in another state must meet the same basic criteria as a Washington
Commission-approved program. All training programs must include educational as well
as experiential training.
In order to have your out-of-state on-the-job (OJT) or academic program approved, you
will need to submit a request for an evaluation of your training program. Your request
for approval of your training must be accompanied by a completed pharmacy technician
application.
DOH 690-121 October 2021 Page 1 of 3
Formal/Academic Training Program
y Instructional and Practical/Experiential Training:
* Ocial transcripts showing a diploma or certicate earned for Pharmacy
Technician; and School catalog describing the coursework; OR
* Ocial transcripts showing a diploma or certicate earned for Pharmacy
Technician; and the signed Adavit of Formal/Academic Technician
Education and Training
AND
y Verication of current active pharmacy practice (mark form with n/a if not
applicable)
y Legal Aspects of Pharmacy Practice
* Adavit of eight hours Washington State pharmacy law study. The
verication of law study form must be signed by a pharmacist currently
licensed to practice in Washington State.
y Copy of National Certication Examination Certicate or Ocial Score Report.
y Letter of Recommendation
Note: Ocial transcript must be sent from your school directly to:
Pharmacy Technician Credentialing
PO Box 47877
Olympia WA 98504-7877
Out-of-State Pharmacy On-the-Job Pharmacy Technician Training Program
y Instructional and Practical/Experiential Training (all items required)
* Adavit of on-the-job Pharmacy Technician Education and Training
* Training course outline
* Letter of Recommendation
* Verication of current active pharmacy practice (mark form with n/a if not
applicable).
AND
y Legal Aspects of Pharmacy Practice
* Adavit of eight hours Washington State pharmacy law study. The
verication of law study form must be signed by a pharmacist currently
licensed to practice in Washington State.
y Copy of National Certication Examination Certicate or Ocial Score Report.
DOH 690-121 October 2021 Page 2 of 3
Military Trained Pharmacy Technicians
The Washington State Pharmacy Commission accepts pharmacy technician training
received through any branch of the U.S. Armed Forces.
y A copy of your DD 214 form, Ocial Joint Service Transcript (JST) or
Community College of the Air Force (CCAF) Transcripts.
y Adavit of eight hours Washington State pharmacy law study. The verication of
law study form must be signed by a pharmacist currently licensed to practice in
Washington State.
y National Certication Examination Certicate or Card
y Letter of Recommendation
y Verication of Active Practice
Foreign Trained Pharmacist or Medical School Degree Graduates
y Educational Training
* Copy of a certied translation of ocial transcript and diploma.
* Proof of passing Test of English as a Foreign Language (iBT).
AND
y Practical/Experiential Training
* 520 hours of supervised experience in a Washington State approved
technician training program.
AND
y Legal Aspects of Pharmacy Practice
* Adavit of 8 hours Washington State pharmacy law study. The verication of
law study form must be signed by a pharmacist currently licensed to practice
in Washington State.
y Test of English as a Foreign Language
* Foreign trained pharmacy technicians where English is not the primary
language must pass the TOEFL iBT. The TOEFL iBT is the sole English
language prociency examination accepted.
TOEFL iBT - minimum passing scores
y Reading: 21
y Listening: 18
y Speaking: 26
y Writing: 24
y Copy of National Certication Examination Certicate or Ocial Score Report.
DOH 690-121 October 2021 Page 3 of 3
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DOH 690-057 October 2021 Page 1 of 5
Revenue: 0262010000
Date
Stamp
Here
Name First Middle Last
Note: The mailing and email addresses you provide will be your addresses of record. It is your
responsibility to maintain current contact information on le with the department.
Country
Will documents be received in another name? F Yes F No
If yes, list name(s):
Address
City State Zip Code County
Phone (enter 10 digit #) Fax (enter 10 digit #) Cell (enter 10 digit #)
Email address
Have you ever been known under any other name(s)? F Yes F No
If yes, list name(s):
Country
Mailing address if dierent from above address of record
City State Zip Code County
Birth date (mm/dd/yyyy)
1. Demographic Information
Pharmacy Technician Application
Please print clearly. Follow all instructions provided. It is the responsibility of the applicant to submit all required
supporting documentation. Failure to do so may result in a delay in processing your application.
Social Security Number (SSN)
(If you do not have a SSN, see instructions)
F Male F Female
F Prefer not to answer
F X
National Provider Identier Number (NPI)
(Enter 10 digit number)
Select if either apply: F Request for Military Training and Experience Evaluation
F Spouse or Registered Domestic Partner of Military Personnel
DOH 690-057 October 2021 Page 2 of 5
1. Do you have a medical condition which in any way impairs or limits your ability to practice your
profession with reasonable skill and safety? If yes, please attach explanation. ...................................... F F
“Medical Condition” includes physiological, mental or psychological conditions or
disorders, such as, but not limited to orthopedic, visual, speech, and hearing impairments,
cerebral palsy, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease, diabetes,
intellectual disabilities, emotional or mental illness, specic learning disabilities, HIV disease,
tuberculosis, drug addiction, and alcoholism.
If you answered yes to question 1, explain:
1a. How your treatment has reduced or eliminated the limitations caused by your medical condition.
1b. How your eld of practice, the setting or manner of practice has reduced or eliminated the
limitations caused by your medical condition.
Note: If you answered “yes” to question 1, the licensing authority will assess the nature,
severity, and the duration of the risks associated with the ongoing medical condition
and the ongoing treatment to determine whether your license should be restricted,
conditions imposed, or no license issued.
The licensing authority may require you to undergo one or more mental, physical or
psychological examination(s). This would be at your own expense. By submitting this
application, you give consent to such an examination(s). You also agree the
examination report(s) may be provided to the licensing authority. You waive all claims
based on condentiality or privileged communication. If you do not submit to a
required examination(s) or provide the report(s) to the licensing authority, your
application may be denied.
2. Do you currently use chemical substance(s) in any way which impair or limit your ability to
practice your profession with reasonable skill and safety? If yes, please explain. .................................. F F
“Currently” means within the past two years.
“Chemical substances” include alcohol, drugs, or medications, whether taken legally or illegally.
3. Have you ever been diagnosed with, or treated for, pedophilia, exhibitionism, voyeurism or
frotteurism? .............................................................................................................................................. F F
4. Are you currently engaged in the illegal use of controlled substances? .................................................. F F
“Currently” means within the past two years.
Illegal use of controlled substances is the use of controlled substances (e.g., heroin, cocaine)
not obtained legally or taken according to the directions of a licensed health care practitioner.
Note: If you answer “yes” to any of the remaining questions, provide an explanation and
certied copies of all judgments, decisions, orders, agreements and surrenders. The
department does criminal background checks on all applicants.
5. Have you ever been convicted, entered a plea of guilty, no contest, or a similar plea, or had
prosecution or a sentence deferred or suspended as an adult or juvenile in any state or
jurisdiction? .............................................................................................................................................. F F
Note: If you answered “yes” to question 5, you must send certied copies of all court
documents related to your criminal history with your application. If you do not
provide the documents, your application is incomplete and will not be considered.
If you have been granted certicate(s) of restoration of opportunity, please
provide a certied copy of each certicate.
To protect the public, the department considers criminal history. A criminal history
may not automatically bar you from obtaining a credential. However, failure to report
criminal history may result in extra cost to you and the application may be delayed
or denied.
2. Personal Data Questions
Yes No
6. Have you ever been found in any civil, administrative or criminal proceeding to have:
a. Possessed, used, prescribed for use, or distributed controlled substances or legend
drugs in any way other than for legitimate or therapeutic purposes? ...............................................F F
b. Diverted controlled substances or legend drugs? .............................................................................F F
c. Violated any drug law? .....................................................................................................................F F
d. Prescribed controlled substances for yourself? ................................................................................F F
7. Have you ever been found in any proceeding to have violated any state or federal law or rule
regulating the practice of a health care profession? If “yes”, please attach an explanation and
provide copies of all judgments, decisions, and agreements? . .............................................................. F F
8. Have you ever had any license, certicate, registration or other privilege to practice a health care
profession denied, revoked, suspended, or restricted by a state, federal, or foreign authority? ............. F F
9. Have you ever surrendered a credential like those listed in number 8, in connection with or to
avoid action by a state, federal, or foreign authority? .............................................................................. F F
10. Have you ever been named in any civil suit or suered any civil judgment for incompetence,
negligence, or malpractice in connection with the practice of a health care profession? ........................ F F
11. Have you ever been disqualied from working with vulnerable persons by the Department
of Social and Health Services (DSHS)? .................................................................................................. F F
2. Personal Data Questions (cont.)
Yes No
DOH 690-057 October 2021 Page 3 of 5
DOH 690-057 October 2021 Page 4 of 5
3. Verication of Education and Training
State/Jurisdiction
3a. Indicate below the process used to verify pharmacy technician education and training and
include required documentation as described in the License Requirements form.
Check only one:
F Completed a Washington State Commission-approved Pharmacy Technician Training Program
F Completed an Out-of-state On-the-job Pharmacy Technician Training Program
F Completed an Out-of-state Formal or Academic Pharmacy Technician Training Program
F Graduate of a foreign pharmacy or medical school degree program or foreign trained Pharmacy Technician
Program
3b. Other License, Certication, or Registration
List all or any states, including Washington, where credentials are or were held. Attach additional completed
pages if you need more space.
License/Certication/Registration Type
License/Certication/Registration
Number
Expiration Date
Issue Date
3c. Professional Experience
List in date order, most recent to later, all your professional experience. Attach additional completed pages if you
need more space.
Name, address and phone number of employer
Nature of experience
End (mm/yyyy)Start (mm/yyyy)
5. Applicant’s Attestation
I, ____________________________________________________, declare under penalty of perjury under the
laws of the state of Washington the following is true and correct:
• I am the person described and identied in this application.
• I have read RCW 18.130.170 and RCW 18.130.180 of the Uniform Disciplinary Act.
• I have answered all questions truthfully and completely.
• The documentation provided in support of my application is accurate to the best of my knowledge.
• I have read all laws and rules related to my profession.
I understand the Department of Health may require more information before deciding on my application. The
department may independently check conviction records with state or federal databases.
I authorize the release of any les or records the department requires to process this application. This includes
information from all hospitals, educational or other organizations, my references, and past and present
employers and business and professional associates. It also includes information from federal, state, local or
foreign government agencies.
I understand I must inform the department of any past, current or future criminal charges or convictions.
I will also inform the department of any physical or mental conditions jeopardize my ability to provide quality
health care. If requested, I will authorize my health providers to release to the department information on my
health, including mental health and any substance abuse treatment.
Dated __________________________________ By: _______________________________________
(Original signature of applicant)
(Print applicant name clearly)
DOH 690-057 October 2021 Page 5 of 5
4. National Certication Exam
Name of Exam________________________________________ Date Taken ____________________________
Certication Number ___________________________________
If dierent, list your name at the time the exam was taken: ____________________________________________
(mm/dd/yyyy)
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DOH 690-215 October 2021
Director’s Certication
Pharmacy Technician Education and Training
Pharmacy Technician Credentialing
PO Box 47877
Olympia, WA 98504-7877
360-236-4700
This form is used to report education and training received through a Pharmacy Quality Assurance
Commission approved Technician Training Program.
The Director’s Certication form must be completed and signed by the training program director as identied
and on le with the Department of Health, Pharmacy Quality Assurance Commission. Any sections left blank
will result in an incomplete or decient application.
Note: The designated program director must sign the certication.
I declare under penalty of perjury under the laws of the state of Washington the following is true and correct:
I attest that the applicant has successfully completed the Pharmacy Quality Assurance Commission approved
program of study and training to become a pharmacy technician.
I attest that the program consisted of the required instructional and supervised practical hours required; not to
exceed 12 months. The program included at a minimum the following topics:
1. Legal aspects of pharmacy practice such as law and rules governing practice.
2. Hygiene/aseptic techniques and safety considerations.
3. Terminology, abbreviations and symbols.
4. Components of a prescription and patient medication record.
5. Drug dosage forms, routes of administration and drug product packaging, weighing and measuring,
packaging and labeling, drug nomenclature, drug standards and information sources.
6. Pharmaceutical calculations.
7. Identication of drugs by trade and generic names, and therapeutic classications.
8. Ordering, restocking, and maintaining drug inventory.
9. Computer applications in the pharmacy.
10. Communication techniques and condentiality of information.
Applicant’s Name:
Dates of instructional and supervised practical training as a pharmacy technician:
Training Program or Pharmacy Name:
Address:
Director’s Name (printed): Director’s License Number(s):
Director’s Email:
Director’s Phone Number:
Is this pharmacy technician training program credentialed or approved by the Pharmacy Quality Assurance
Commission? F No F Yes Credential/Approval number ________________ (enter n/a if this does not apply)
Start Date (MM/DD/YYYY): Completion Date: (MM/DD/YYYY):
Pharmacy License Number (if applicable):
Telephone Number:
Director’s Signature:
Date (mm/dd/yyyy):
City Zip CodeState
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DOH 690-216 October 2021 Page 1 of 2
Afdavit of An Out of State Formal Academic
Pharmacy Technician Education and Training Program
Pharmacy Technician Credentialing
PO Box 47877
Olympia, WA 98504-7877
360-236-4700
Ocial Representative or Registrar’s Attestation
I declare under penalty of perjury under the laws of the state of Washington the following is true and
correct:
y I am the person that oversees the pharmacy technician training program.
y I personally supervised or have knowledge of the applicant’s successful completion of a
program of education and training for pharmacy technician in the pharmacy identied below
and licensed by the state of___________________________________________________.
y I attest that the training program completed by the applicant included a total of ___________
hours of classroom instruction.
y I attest that the training program completed by the applicant included a total of ___________
hours of experiential/practical training.
y I attest that the technician training program included at a minimum the following topics of
instructions and practical training:
F Legal aspects of pharmacy practice such as law and rules governing practice.
F Hygiene/aseptic techniques and safety considerations.
F Terminology, abbreviations and symbols.
F Components of a prescription and patient medication record.
F Drug dosage forms, routes of administration and drug product packaging, weighing and
measuring, packaging and labeling, drug nomenclature, drug standards and information sources.
F Pharmaceutical calculations.
F Identication of drugs by trade and generic names, and therapeutic classications.
F Ordering, restocking, and maintaining drug inventory.
F Computer applications in the pharmacy.
F Communication techniques and condentiality of information.
I attest that the program of instructional and supervised practical training is outlined in the attached
written plan that shall be available to the Pharmacy Quality Assurance Commission upon request.
This form is used to report education and training received outside of Washington State. It may not
be used to report education and training received in Washington State.
The Adavit of An Out of State Formal Academic Education and Training Program form must
be accompanied by ocial transcripts showing a diploma earned and extern hours completed
for pharmacy technician. The form must be completed by an ocial representative of the formal
education program. Any sections left blank will result in an incomplete or decient application.
Applicant’s Name:
Dates of instructional and supervised practical training as a pharmacy technician:
Name of School:
Address of School:
Ocial Program Representative (print name):
Ocial Program Representative (print title):
Ocial Program Representative Email Address: Telephone Number:
Signature of Ocial Program Representative: Date (mm/dd/yyyy):
Is this pharmacy technician training program credentialed or approved by the Pharmacy Quality Assurance
Commission?
F No F Yes
Credential/Approval number ____________________ (enter n/a if this does not apply)
Start Date:
Completion Date:
DOH 690-216 October 2021 Page 2 of 2
DOH 690-217 October 2021 Page 1 of 2
Afdavit of An Out of State On-the-Job
Pharmacy Technician Education and Training
Pharmacy Technician
Credentialing
PO Box 47877
Olympia, WA 98504-7877
360-236-4700
I declare under penalty of perjury under the laws of the state of Washington the following is true and
correct:
y Attached is a true and accurate course outline of the training received by the applicant
identied below.
y I am the person that oversees the pharmacy technician training program.
y I personally supervised or have knowledge of the applicant’s successful completion of a
program of education and training for pharmacy technician in the pharmacy identied below
and licensed by the state of ________________________________________.
y I attest that the training program completed by the applicant included a total of __________
hours of instruction including didactic and practical training.
y I attest that the technician training program included at a minimum the following topics of
instruction and practical training:
F Legal aspects of pharmacy practice such as law and rules governing practice.
F Hygiene/aseptic techniques and safety considerations.
F Terminology, abbreviations and symbols.
F Components of a prescription and patient medication record.
F Drug dosage forms, routes of administration and drug product packaging, weighing and
measuring, packaging and labeling, drug nomenclature, drug standards and information sources.
F Pharmaceutical calculations.
F Identication of drugs by trade and generic names, and therapeutic classications.
F Ordering, restocking, and maintaining drug inventory.
F Computer applications in the pharmacy.
F Communication techniques and condentiality of information.
I attest that the program of instructional and supervised practical training is outlined in a written plan
that shall be available to the Pharmacy Quality Assurance Commission upon request.
This form is used to report education and training received outside of Washington State. It may not be
used to report education and training received in Washington State or outside of the United States.
Note: The adavit of An Out of State On the Job Education and Training Program form must be
accompanied by the program course outline. The form must be completed by the supervising
pharmacist. Any sections left blank or omission of course outline will result in an incomplete or
decient application.
Supervising Pharmacist’s Attestation
DOH 690-217 October 2021 Page 2 of 2
Applicant’s Name:
Is this pharmacy technician training program credentialed or approved by the Pharmacy Quality Assurance
Commission?
F No F Yes
Credential/Approval number ____________________ (enter n/a if this does not apply)
Start Date:
Completion Date:
Dates in which instructional and supervised practical training was received:
Pharmacy Name: State License Number:
Address of Pharmacy: Phone Number:
Supervising Pharmacist’s Name (print):
Supervising Pharmacist’s License Number(s):
Supervising Pharmacist’s Signature:
Date (mm/dd/yyyy):
Verication of Current Active Pharmacy Practice
____________________________________________________________ has been employed as a
F Pharmacy Technician
F Pharmacist
F Other, please explain _____________________________________________________________
by this organization from _____________________________ until ___________________________.
Pharmacy/Employer Information:
Person Completing Form:
Name _________________________________ Phone (enter 10 digit #) _______________________
Email Address_____________________________________________________________________
Credential type and number (if applicable) _______________________________________________
Title _____________________________________________________________________________
Name ________________________________ Phone (enter 10 digit #) _______________________
Pharmacy State License Number (if applicable)___________________________________________
Email Address_____________________________________________________________________
Street Address_____________________________________________________________________
City ____________________State ___________________________Zip Code __________________
Pharmacy Quality Assurance
Commission Credentialing
PO Box 47877
Olympia, WA 98504-7877
360-236-4700
DOH 690-104 October 2021
(Print applicant name clearly)
Signature __________________________________ Date__________________________________
(mm/dd/yyyy) (mm/dd/yyyy)
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Applicant’s Name __________________________________________________________________
To be completed by recommender:
I have known the applicant for approximately: ________ years ________months
My relationship to the applicant was (or is) in the following capacity:
F Employer F Supervisor F Co-worker
I hereby certify that I am a licensed pharmacist in good standing in the state of _________________.
My license/certication number is: _____________________________________________________
I further certify that I have been personally acquainted with _________________________________
and that to the best of my knowledge, I believe he or she is of good moral and professional character.
I conrm that he or she is free from habits liable to interfere with his or her professional services.
Remarks:________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Print Name: ______________________________________________________________________
Street Address or PO Box: ___________________________________________________________
City: ___________________ State: ___________________________ Zip Code: ________________
Email Address: ____________________________________________________________________
Daytime Phone (enter 10 digit #):______________________________________________________
Signature: _____________________________________________ Date: _____________________
DOH 690-218 October 2021
Pharmacy Technician Credentialing
PO Box 47877
Olympia, WA 98504-7877
360-236-4700
Pharmacy Technician
Letter of Recommendation
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Law Study Verication
DOH 690-102 October 2021
_____________________________________________________ has completed a
minimum of eight hours of study and discussion of Washington State pharmacy law
under my supervision and possesses a working knowledge of this law.
Pharmacist information:
Printed name:
Signature:
WA License number:
Pharmacist contact information:
Name:
Street:
City:
Phone (enter 10 digit #):
Date:
Email Address:
Pharmacy Technician Credentialing
PO Box 47877
Olympia, WA 98504-7877
360-236-4700
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RCW/WAC Links
Uniform Disciplinary Act, RCW 18.130
Administrative Procedure Act, RCW 34.05
Administrative Procedures and Requirements, WAC 246-12
Pharmacy Technician Laws, RCW 18.64A
Pharmacy Technician Rules, WAC 246-945
Online
Pharmacy Quality Assurance Commission, Website
RCW/WAC and Online Website Links
RCW/WAC and Online Website Links October 2021
