UBTech Practical Nursing Application

Uintah Basin Technical College Pharmacy Technician Application

Info
Thank you for your interest in the Pharmacy Technician program at Uintah Basin Technical College (UBTech). The Pharmacy Technician program at UBTech is accredited by the American Sociaty of Health-Systems Pharmacists (ASHP). For more information, contact ASH{ at 4500 East-West Highway, Suite 900 Bethesda, MD, 20814, phone (866) 279-0681, or visit https://www.ashp.org/

Step 1 - There are a few requirements that will need to be completed before applying to the Pharmacy Technician program.

We require an official verification of High School graduation or GED for post-secondary students. Secondary students must be 17 years of age upon the first day of the program and on track to graduate with verification from high-school counselor in order to participate in the program. Students who are not 18 years of age will need to do extra paperwork with some externship sites to be able to attend clinicals.

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Step 2 - All entrance testing must be submitted:

Option 1: Where applicable, students may submit ACT scores instead of academic assessment exams. Scores must be 19+ in each category, and must be within the last 2 years to be accepted.

Option 2: Take and pass all areas of Uintah Basin Technical College's academic assessment exam for the Pharmacy Technician program. A minimum of 4-6 weeks before the deadline is recommended. Contact the Student Success Advisor's by visiting the UBTech Admissions Page to schedule an appointment. Include a copy of the test resullts with your application.

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Step 3 - Complete the Uintah Basin Technical College Pharmacy Technician program application. Applications must be received by the application deadline; or, if the deadline is on a weekend, the last business day prior. The applicant is responsible to collect and return the materials listed on the Application Checklist sheet as a complete packet.

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Step 4 - (Optional) - Depending on number of qualified applicants, an interview may be necessary.
The "Save" button, which is located on each page of this application, will save your application and send you a link that will allow you to edit and update your application until all parts of the application are complete.

Uintah Basin Technical College Pharmacy Technician Application

Contact
Contact Information
Name*

First NameLast Name
Other last names (maiden name, previous married name, etc.)
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Cell Phone*
Please enter a valid phone numberFormat: (000) 000-0000.
Which county do you reside in?*
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone numberFormat: (000) 000-0000.
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different than home address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ApplicantAlternateNo
6/8/20268/19/20263/8/20275/24/2027Any
The "Save" button, which is located on each page of this application, will save your application and send you a link that will allow you to edit and update your application until all parts of the application are complete.

Uintah Basin Technical College Pharmacy TEchnician Application

Testing
Uintah Basin Technical College Academic Placement Testing
Placement testing must be completed in the UBTech testing center sooner than 1 week before the application deadline. An appointment is needed. Contact the Student Success Advisor's by visiting the UBTech Admissions Page to schedule an appointment.
Please scan and upload your ACT results and/or UBTech exam results below:*

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All files must be submitted as a PDF file type. If you don't have access to a scanner, you can save files to your computer with an app such as Adobe Scan or CamScanner.
The "Save" button, which is located on each page of this application, will save your application and send you a link that will allow you to edit and update your application until all parts of the application are complete.

Uintah Basin Technical College Pharmacy Technician Application

Experience
Education

List any high schools/colleges/universities attended*

Rows	Name of School	Dates Attended (Month/Year)
1
2
3
4
5

List any honors and special awards you have received throughout your education.
Work Experience
List most recent work experience first. If none, indicate by N/A.
Job Title
Company Name
Phone Number
Please enter a valid phone numberFormat: (000) 000-0000.
Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor Name

First NameLast Name
Job Description
Full-time (32+ hrs/wk)Part-time (2-31 hrs/wk)
Total months employed
From

MonthDayYear
Date
To

MonthDayYear
Date
Job Title
Company Name
Phone Number
Please enter a valid phone numberFormat: (000) 000-0000.
Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor Name

First NameLast Name
Job Description
Full-time (32+ hrs/wk)Part-time (2-31 hrs/wk)
Total months employed
From

MonthDayYear
Date
To

MonthDayYear
Date
Job Title
Company Name
Phone Number
Please enter a valid phone numberFormat: (000) 000-0000.
Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor Name

First NameLast Name
Job Description
Full-time (32+ hrs/wk)Part-time (2-31 hrs/wk)
Total months employed
From

MonthDayYear
Date
To

MonthDayYear
Date
The "Save" button, which is located on each page of this application, will save your application and send you a link that will allow you to edit and update your application until all parts of the application are complete.

Uintah Basin Technical College Pharmacy TEchnician Application

References
References
List the names of the three professional people who will be completing your reference evaltuation forms. These must be people who are now or who have been your employer, supervisor, former instructor, or community leader. They must have known you for at least six months and cannot be related to you.
Reference 1*

First NameLast Name
Company*
Position*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Reference 2*

First NameLast Name
Company*
Position*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Reference 3*

First NameLast Name
Company*
Position*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
*It is the reponsibility of the applicant to ensure all forms are competed and submitted by the application deadline.
The "Save" button, which is located on each page of this application, will save your application and send you a link that will allow you to edit and update your application until all parts of the application are complete.

Uintah Basin Technical College Pharmacy Technician Application

Immunizations
Immunizations
MMR X2 (Measles, Mumps, Rubella)Varicella X2 or History of Chicken Pox or TiterHepatitis B X3T-dap X1 (in the last 10 years)TB skin test or Quantiferon (only good for 1 year and must be current throughout the program)Annual Influenza vaccination (Oct 1 - March 31)
Please download and complete the Nursing Student Immunization Requirements form found below. Once completed, upload the form below.
Upload the completed Nursing Student Immunization Requirements Form*

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All files must be submitted as a PDF file type. If you don't have access to a scanner, you can save files to your computer with an app such as Adobe Scan or CamScanner.
Upload your immunization record (can be received from the Health Department)*

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All files must be submitted as a PDF file type. If you don't have access to a scanner, you can save files to your computer with an app such as Adobe Scan or CamScanner.
The "Save" button, which is located on each page of this application, will save your application and send you a link that will allow you to edit and update your application until all parts of the application are complete.

Uintah Basin Technical College Pharmacy Technician Application

Goals
Professional Goal Statement
Using the space provided below, Write a statement of your professional goals.

Your statement will be reviewed based on the following criteria:
- The statement must be a minimum of 150 words and a maximum of 200 words.
- The statement will be graded on spelling, puctuation, grammar, and sentence structure.
Type your response below:*

0/200
The "Save" button, which is located on each page of this application, will save your application and send you a link that will allow you to edit and update your application until all parts of the application are complete.

Uintah Basin Technical College Practical Nursing Application

Checklist
Application Checklist

Complete the following checklist. It is your responsibility to ensure that all items are completed. Please note that any missing information will render your file incomplete and you will not be considered a possible candidate for this program
I have completed Uintah Basin Technical College's Placement Testing and have attached a copy of the exam's score sheet given to me by the testing specialist or I have uploaded my ACT results.I have fully completed each tab on UBTech's Online Pharmacy Technician Application.I understand that it is my responsibility to ensure that all reference evaluation forms are completed by the reference by the application deadline.I understand that after acceptance into the program, I will be required to submit to a criminal background check and urine drug screen.I have marked every line of this application checklist as completed. I understand that failure to provide the above information by the application deadline will render my file incomplete and it will be returned.Once my application has been submitted, I will email the Health Professions Administrative Assistant (kirby@ubtech.edu) and make sure it's been received.
The "Save" button, which is located on each page of this application, will save your application and send you a link that will allow you to edit and update your application until all parts of the application are complete.

Uintah Basin Technical College Practical Nursing Application

Application Agreement
By signing via Adobe Sign below, I agree that the information provided is accurate to the best of my knowledge. I understand that providing false or misleading information regarding any information I have provided on these forms may render my application incomplete. I verify that I have been given information about the following prior to enrollment:
- Qualifications to enroll;
- The purpose of the training program;
- Requirements for state registration or licensure as a pharmacy technician;
- Requirements for obtaining and maintaining national pharmacy technician certification;
- Programmatic and institutional accreditation status;
- Prospects for employment;
- Realistic salary expectations or referral to local, state, or national statistics for salary expectations;
- Total program cost;
- The program's dismissal policy including acedemic and non-academic and non-academic criteria, including, but not limited to the organizations Student Code of Conduct; and
- Graduate performance on national exams posted on public-facing materials and websites.
The "Save" button, which is located on each page of this application, will save your application and send you a link that will allow you to edit and update your application until all parts of the application are complete.

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Uintah Basin Technical College Pharmacy Technician Application

Uintah Basin Technical College Pharmacy Technician Application

Contact Information

Uintah Basin Technical College Pharmacy TEchnician Application

Uintah Basin Technical College Academic Placement Testing

Uintah Basin Technical College Pharmacy Technician Application

Education

Work Experience

Uintah Basin Technical College Pharmacy TEchnician Application

References

Uintah Basin Technical College Pharmacy Technician Application

Immunizations

Uintah Basin Technical College Pharmacy Technician Application

Professional Goal Statement

Uintah Basin Technical College Practical Nursing Application

Application Checklist

Uintah Basin Technical College Practical Nursing Application