Pharmacist Interns

Form I

Pharmacist Intern Application.pdf

Once you have completed this application, please print, date and sign then submit to the Board office along with a wallet sized photo, letter of acceptance into a college of pharmacy or a copy of your FPGEC certificate for foreign graduates any payment of $25. Checks made payable to 'Kentucky State Treasurer'. In the event your registration card is either lost or destroyed, a duplicate card may be requested. Please indicate your registration number in all correspondence.

Form II

Pharmacist Preceptor Affidavit.pdf

Preceptor Affidavit must be submitted within ten (10) days from beginning of internship. Preceptor Affidavit must be resubmitted within ten (10) days if there is a change in preceptor.

Form III

Pharmacist Internship Report.pdf

Intern hours will not be accepted if the Preceptor Affidavit is not on file.

Form IV

Academic Experience Affidavit.pdf

The Board requires notification of name changes within thirty days. The Board requests that these requests be submitted by fax, 502-696-3806 or email, pharmacy.board@ky.gov. All name changes must be supported with at least one of the following: a marriage certificate, a divorce decree, or an official court document authorizing the name change.