Fillable LICENSE FEE: Use the chart below to determine (Nebraska)

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LICENSE FEE: Use the chart below to determine (Nebraska)

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Pages 1 of 15
LICENSE FEE: Use the chart below to determine your applicable licensing fee. The prorated fee is applicable if the
Licensure Unit issues your license during those months. Pay by check/money order (your cancelled check is your
proof of receipt).
Licensure Fee is $25.00
LICENSE FEE WAIVER: Starting January 1, 2020, if you meet one of the following waiver options, your initial license
and temporary license fee is waived.
1. Young Worker: You are between the ages of 18 and 25 (under the age of 26).
2. Low-Income Individual: You are enrolled in a state or federal public assistance program such as the medical
assistance program established pursuant to the Medical Assistance Act, the federal Supplemental Nutrition
Assistance Program (SNAP), or the federal Temporary Assistance for Needy Families (TANF) program, OR your
household adjusted gross income is below 130% of the federal income poverty guideline.
If you live in Nebraska and are enrolled in a state or federal public assistance program, no further documentation
is required to be submitted.
If you live in a state other than Nebraska and are enrolled in a state or federal public assistance program, submit a
copy of a document showing current enrollment.
If your household adjusted gross income is at 130% of the Federal Income Poverty Guideline or below, click this
link to see the current income guidelines,
http://dhhs.ne.gov/licensure/documents/LowIncomeFeeWaiverTable.pdf. To be eligible for this waiver, you must
submit a copy of your most recent tax return.
3. Military Family: You are an active duty service member in the armed services of the United States, a military spouse,
honorably discharged veteran of the armed services of the United States, spouse of such honorably discharged veteran,
and un-remarried surviving spouses of deceased service members of the armed services of the United States. To be
eligible for this waiver, you must submit a copy of your ID card, discharge paperwork, or similar document that shows
you are a military family member as described above.
MILITARY: To view licensing services available to members of the military and their spouses, visit our website at
http://dhhs.ne.gov/licensure/Pages/Professions-and-Occupations.aspx
1. US Citizenship/Lawful Presence
U.S. Citizens, a PHOTOCOPY of one of the following:
____ Birth certificate (Hospital issued keepsake birth certificates cannot be accepted).
____ U.S. Passport (unexpired or expired).
____ Certificate of Naturalization.
____ Other documents that show U.S. Citizenship.
A Driver’s License is NOT acceptable.
NOT a U.S. Citizen (Current Immigration Status) a PHOTOCOPY of one of the following:
____ Green Card, otherwise known as a Permanent Resident Card (Form I-551), both front and back of the card;
____ Form I-94 (Arrival-Departure Record) AND an unexpired foreign passport with a valid unexpired US visa; or
____ Employment Authorization Card AND one of the following
____ An approved deferred action status (DACA);
____ A pending application for asylum in the United States;
Application Information for
Nebraska Pharmacy Technician Registration
Application Section A – Personal Information (Provide copies of the following documents)
Pages 3 of 15
____ A pending or approved application for temporary protected status in the United States; or
____ A pending application for adjustment of status to that of an alien lawfully admitted for permanent
residence in the United States or conditional permanent resident status in the United States
____ Other document that shows current immigration status
***NOTE: Documents (other than those for U.S. Citizenship) are verified by our office through the Department of
Homeland Security. This process may take 4-6 weeks.
2. Proof of being at least 18 years old. Include with your application a copy of your driver’s license, state identification
card, birth certificate, or other acceptable government-issued identification.
1. Drug Related Conviction: If you have ever been convicted of a drug-related offense, you are not eligible to receive a pharmacy
technician registration.
2. Conviction Information: If you have EVER received a ticket from law enforcement or animal control, check the court system
to see if the ticket is on your record as a misdemeanor or felony conviction. Speeding tickets are not misdemeanors or felonies.
You are required to list ALL convictions (regardless of when they occurred) on the application; you are NOT required to list
infractions, diversions or dismissals. Misdemeanor and felony convictions can either be processed through traffic or criminal
court, so when you check with the county court/district court, you should ask for both traffic and criminal court misdemeanor/felony
convictions.
If you have convictions, you must submit:
(i) A copy of the court record related to all misdemeanor and felony convictions, that includes the statement of charges
and final disposition, if the conviction(s) occurred in a state other than Nebraska;
(ii) An explanation of the events leading to the conviction (what, when, where, why) and a summary of actions that the
applicant has taken to address the behaviors or actions related to the conviction; and
(iii) A letter from the applicant’s probation officer addressing the terms and current status of the probation, if the applicant
is currently on probation.
If you had an alcohol and drug evaluation and/or completed treatment, to assist the Board and Department in review
of any drug and/or alcohol conviction(s), we encourage you to request that the treatment provider submit all evaluations
and discharge summaries directly to the Department.
The following provides SOME examples of convictions; this is NOT a complete list
MIP/ Tobacco Use by Minor
DUI / DWI / Open Container
Controlled Substance
Shoplifting / Theft / Burglary
Unauthorized use of a Financial Transaction
Disturbing the Peace
Assault / Prostitution
Disorderly Conduct / Disorderly House
Fail to Appear in Court
Driving under Suspension / Revocation
License Vehicle without Liability Insurance
False Information or Reporting
Reckless Driving / Leave the Scene of an Accident
Operator not Carrying License
Unlawful Display of Plates/Renewal tabs
Park Rule Violation / Curfew Violation
Dog at Large / Fail to Vaccinate Animal
Littering / Fireworks / Bad Check
NOTE: If you have any criminal charges or license disciplinary actions pending that result in a conviction or license
discipline, you are required to report such action to the Investigative Unit within 30 days of the conviction or disciplinary
action. Reporting forms can be obtained at the following website: http://dhhs.ne.gov/Pages/Investigations.aspx or by
phone 402-471-0175.
3. Other State License Information: If you hold or have held a health related license in any state (other than Nebraska) our
office may contact you and request that you contact that state and request a certification/verification of your license (do not
send a copy of your license).
Application Section B – Conviction and Licensure Information (Provide copies of the following documents)
1. Proof of High School Graduation or Equivalent: Submit a copy of your high school diploma or high school
transcripts showing date of graduation. We will also accept college transcripts (if they show your date of high school
graduation) or a college diploma.
All applicants must complete this section. An individual who practices prior to the issuance of a credential is subject to an
assessment of an Administrative Penalty of $10 per day up to $1,000, or such other action as provided in the statutes and
regulations governing such credential.
All applicants are required to complete this section.
OTHER INFORMATION:
Any documents written in a language other than English must be accompanied by a complete translation into the English
language. The translation must be an original document and contain the notarized signature of the translator. An
individual may not translate his/her own documents.
TIME FRAME FOR PROCESSING:
License Decision: 8-10 weeks from receipt of a completed application
Please note:
1. You have 90 days to complete an application. If your application is not completed after 90 days, your application
and all supporting documents will be destroyed and a refund will be processed, less a $25 administrative fee.
2. If an individual other than the applicant pays the licensure fee, refunds will be issued to that individual and their
social security number will be required to process the refund.
3. If a business entity will be paying the licensure fee, refunds will be issued to that business entity and a copy of
their W-9 is required to process the refund.
Contact Information: Licensure Unit, 301 Centennial Mall South, PO Box 94986, Lincoln NE 68509-4986
Telephone: 402-471-2118 / FAX: 402-742-8355 / E-Mail: dhhs.medicaloffice@nebraska.gov
Application Review: All applications are reviewed in date order received. If a preliminary review shows that you are
missing information, you will be contacted by e-mail within approximately 15 days.
If your application is missing information, you will be contacted by e-mail within approximately 10 days; the e-mail will list
the information that is required to compete your application. You have 90 days to complete your application; if not
completed within this 90 days, your application will be closed and all documents destroyed. A new application will then be
required.
If your application is complete, you will receive by e-mail that your license has been issued.
Records Retention Schedule: When your license is issued, your application and documents will be kept by the Department for 5
years; then all documents will be destroyed. We encourage you to keep a copy of your application for your records.
This form may be printed and mailed to the address listed below.
Division of Public Health
Licensure Unit
P O Box 94986
Lincoln NE 68509-4986
Fee Waiver:
If you meet one of the following fee waivers, your initial license and temporary license fee is waived. Check only ONE waiver:
□ Young Worker: I am under 26 years old.
□ Low-income Individual:
□ I am enrolled in a state or federal public assistance program, including, but not limited to, the medical assistance program
established pursuant to the Medical Assistance Act, the federal Supplemental Nutrition Assistance Program, or the federal
Temporary Assistance for Needy Families program; OR
□ My household adjusted gross income is below 130% of the federal income poverty guideline.
□ Military Family: I am an active duty service member in the armed services of the United States, a military spouse, honorably
discharged veteran of the armed services of the United States, spouse of such honorably discharged veteran, and un-remarried
surviving spouses of deceased service members of the armed services of the United States.
SECTION A - PERSONAL INFORMATION
Legal Name:
Last:
First:
Middle/Maiden:
Other Names
Known As:
Mailing Address:
Street/PO/Route:
City:
State:
Zip:
Date of Birth (mm/dd/yyyy):
Place of Birth (City/State or Country):
Telephone Number: (Optional)
E-mail/Fax: (Optional)
Check the appropriate box:
Social Security Number (SSN);
Alien Registration Number (“A#”); or
Form I-94 (Arrival-Departure Record)
number
SSN:
A#:
I-94 #:
NOTE: If you have both a SSN and an A# or I-94 number, you must report both. Neb. Rev. Stat. §38-123 mandates disclosure of
your social security number to DHHS. Although your number is not public information, DHHS may disclose it for child
support enforcement purposes and to the Nebraska Department of Revenue.
OFFICE USE ONLY
NDEN
Yes__
No___
BOARD
Yes__
No___
APPLICATION FOR REGISTRATION AS A
PHARMACY TECHNICIAN
BU #25550149
Fee: $25
SECTION B – CONVICTION AND LICENSURE INFORMATION (All applicants must complete this section, if they hold or
have held a license in another state or jurisdiction) Direct source verification to the Licensure Unit is required for all licenses. Failure to disclose
disciplinary action, regardless of when the action occurred, could result in disciplinary action, including but not limited to, censure or civil
penalty.
Have you ever been
convicted of any non-alcohol,
drug-related misdemeanor or
felony?
YES
NO
Type of Crime
Date of
Action
Name of Court Taking Action
(City/County/State)
CONVICTION INFORMATION: You must list ALL misdemeanor or felony convictions (regardless of when they occurred).
1
Have you EVER been
convicted of a
misdemeanor or felony?
Name of Conviction
Date of Action
Name of Court Taking
Action
Yes □ No □
The following provides SOME examples of convictions; this is NOT a complete list
MIP/ Tobacco Use by Minor
DUI / DWI
Controlled Substance
Open Container
Shoplifting / Theft / Burglary
Unauthorized use of a Financial Transaction
Disturbing the Peace
Assault / Prostitution
Disorderly Conduct / Disorderly House
Reckless Driving
Driving under Suspension / Revocation
License Vehicle without Liability Insurance
Fail to Appear in Court
False Information or Reporting
Leave the Scene of an Accident
Operator not Carrying License
Unlawful Display of Plates/Renewal tabs
Park Rule Violation / Curfew Violation
Dog at Large / Fail to Vaccinate Animal
Littering / Fireworks / Bad Check
LICENSE INFORMATION: The following questions relate to a license that you currently hold or have held in a state other than
Nebraska.
1
Do you hold or have you held a license in
any other state(s)?
If yes, what state(s)?
What type of license?
Yes □ No □
If YES, has your license ever been denied,
refused renewal, limited, suspended,
revoked or had other disciplinary measures
taken against it?
Type of Action
Date of Action
Name of State Taking Action
Yes □ No □
PLEASE NOTE: If you have any criminal charges or license disciplinary actions pending that results in conviction or license discipline,
you are required to report such actions to the Investigations Unit within 30 days http://dhhs.ne.gov/Pages/reg_invest-p.aspx or by
telephone at 402-471-0175.
SECTION D – PRACTICE PRIOR TO CREDENTIAL (All applicants must complete this section) An individual who practices
prior to the issuance of a credential is subject to an assessment of an Administrative Penalty of $10 per day up to $1,000, or
such other action as provided in the statutes and regulations governing such credential.
NO I have not practiced as a pharmacy technician in Nebraska without a registration.
YES I have practiced as a pharmacy technician in Nebraska without a registration.
Name of Business:
City:
Telephone #:
SECTION C – EDUCATION
Mark the Appropriate Box:
High School Diploma
GED
Mailing Address:
DHHS, Division of Public Health
Licensure Unit – 1
st
Floor
P.O. Box 94986
Lincoln, Nebraska 68509-4986
Physical Address:
DHHS, Division of Public Health
Licensure Unit- 1
st
Floor
301 Centennial Mall South,
Lincoln, Nebraska 68508
SECTION E – ATTESTATION
Attestation: For the purpose of complying with Neb. Rev. Stat. §§4-108 through 4-114 and 38-129 (check ONE of the
boxes below):
I attest that:
I am a citizen of the United States.
OR
I am a qualified alien under the Federal Immigration and Nationality Act.
I am a nonimmigrant lawfully present in the United States.
Check this box if you are NOT a citizen of the United States, a nonimmigrant, nor a qualified alien
under the Federal Immigration and Nationality Act.
NOTE: You may still be eligible for a credential if you provide a photocopy of your unexpired Employment Authorization
Document (EAD) and evidence of meeting section 202(c)(2)(B)(i) through (ix) of the Federal REAL ID Act of 2005.
Application Attestation: I attest that:
1. I have read the application or have had the application read to me; and
2. All statements on this application are true and complete.
Print Name: _____________________________________
Signature: _______________________________________ Date: ___________________
Contact Information:
Telephone: 402-471-2118
Email: DHHS.medicaloffice@nebraska.gov
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Completed 15 March 2021

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