PrimaryPlus Pharmacy Technician Program Application

PrimaryPlus Pharmacy Tech. Program Application
*Important Information for Applicants*

Before you begin your application, please read the following details carefully:

1. Transportation: You are responsible for getting to and from PrimaryPlus.

2. Not a Paid Position: This program is not a paid position or job offer.

3. Certification Requirement: To be eligible for the Certified Pharmacy Technician exam, you must complete a total of 500 training hours.

4. Co-op Structure: This program will be a co-op, meaning you must schedule it around your school schedule, classes, job, etc.

5. What You Will Do: You will work alongside pharmacists and other technicians, where you will learn skills such as basic drug information, counting, labeling, stocking, sorting, customer service, and calculations.

Make sure you understand these details before proceeding with your application!

Application deadline: August 15th, 2025

Program start date: September 8th, 2025.
I. DEMOGRAPHICS
High School:*
School County:*
School Phone:*
Graduation Year:*
First Name:*
MI:
Last Name:*
Address:*
City:*
State:*
Zip Code:*
Home Phone:
Cell Phone:*
Alternate Phone:
Email Address:*
Date of Birth:*

MonthDayYear
YesNo
MaleFemale
African-AmericanCaucasianHispanicAsian or Pacific IslanderNative American or AlaskanOther
YesNo
If yes, please explain:
II. HOUSEHOLD / EMERGENCY CONTACT INFORMATION
Emergency Contact:
Name:*
Relationship: *
Phone Number:*

Area CodePhone Number
YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
III. STUDENT PROFILE
Extracurricular Activities, Hobbies, and Interests: List the extracurricular activities, hobbies, and interests in which you have been involved and provide a description of your contribution to that activity. *
V. STUDENT REFERENCE
*Must be a teacher reference*
Teacher Name:*
Title/Role:
Phone:
Email Address:*
VI. STUDENT CONSENT AND AGREEMENT
By signing my digital signature below, I hereby certify that the information provided on this application and attachments I have provided is true and accurate to the best of my knowledge. I commit myself to abide by the rules and expectations of the PrimaryPlus Pharmacy Tech. Program.
Signature*
MonthDayYear
Date
VII. PARENT/GUARDIAN CONSENT FORM
Click here for Parent/Guardian Consent Form
In order for your application to be accepted, a signed copy of the PrimaryPlus Parent/Guardian Release Form.*

Select File

Cancelof
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PrimaryPlus Pharmacy Tech. Program Application