ARIZONA STATE BOARD OF PHARMACY
P. O. Box 18520 Phoenix, AZ 85005
p ) 602-771-2727 f ) 602-771-2749
www.azpharmacy.gov
APPLICATION FOR CERTIFICATION TO PERFORM IMMUNIZATIONS
REQUIREMENTS:
New applicants are required to attach proof of completion of a training program specified in A.A.C. R4-23-411, as well as proof of current CPR.
Renewal applicants are required to attach proof of current CPR as well as 5.0 units of Continuing Education credit relating to immunization.
PLEASE PRINT OR TYPE YOUR INFORMATION
PLEASE NOTE:
Interns are not to give immunizations unless under the supervision of a licenced pharmacist who also holds a valid immunization certificate.
To the best of my knowledge and belief the foregoing application is true and current in all respects.
(Signature) (Date)
Title II of the Americans with Disabilities ACT prohibits the Arizona State Board of Pharmacy from discrimination on the basis of disability. This material is
available in an alternate format upon request.
RD080111
( Application Type ) ( check one )
New Certification
Renewal for Existing Certificate No.:
( Pharmacist / Intern License No. ) ( Expiration ) ( mm/dd/yyyy ) ( Current CPR Expiration ) ( mm/dd/yyyy ) ( attach copy )
( Name )
( SSN ) ( 123-45-6789 )
( Street Address ) ( City ) ( County ) ( St ) ( Zip Code )
( E-mail Address ) ( Phone ) (123-456-7890 )
( Mailing Address if different ) ( City ) ( County ) ( St ) ( Zip Code )
( Pharmacy Name )
( Street Address ) ( City ) ( County ) ( St ) ( Zip Code )
