Revised 072614
P.O. Box 198788
Nashville, TN 37219
The Massachusetts Board of Registration in Pharmacy (Board) has contracted with Professional Credential Services
(PCS) to process registration applications from pharmacy technicians. Applicants must submit all information directly
to PCS. Applicants must meet one of the following registration requirements to be licensed as a Pharmacy Technician
in Massachusetts:
Registration Requirements for Non-Certified Applicants (247 CMR 8.02)
1) Be at least 18 years of age.
2) Be of good moral character and not been convicted of a drug-related felony.
3) Have a high school diploma or equivalent or currently enrolled in a program that awards such degree or certificate.
4) Have completed a Board-approved training program or a minimum of 500 hours of employment as a pharmacy
technician trainee.
5) Passed a Board-approved pharmacy technician assessment examination administered by the employer or the
employer’s agency
Registration Requirements for Certified Applicants (247 CMR 8.04)
1) Be at least 18 years of age
2) Be of good moral character and not been convicted of a drug-related felony
3) Have a high school diploma or equivalent or currently enrolled in a program that awards such a degree or certificate
4) Currently certified by the Exam for the Certification of Pharmacy Technician (EXCPT) or the Pharmacy Technician
Certification Board (PTCB).
Application Instructions
Applicants must complete the attached application and submit it to PCS with required fees. Applications should be
typewritten or legibly printed in blue or black ink. An applicant must have a Social Security Number or an Affidavit in
Support of Registration to be registered with the Board. The applicant must sign the completed application in the
presence of a notary public and attach a 2” x 2” photo of the applicant. Non-Certified Applicants: A Pharmacy
employer must verify employment history by completing the Employer Verification of Experience and Examination
form enclosed. Certified Applicants must provide a copy of their current PTCB/EXCPT Certification Registration.
Applicants registered as a Pharmacy Technician in another U.S. jurisdiction must attach a letter of official verification
from the Board of original registration. A copy of the certificate will not be accepted.
Once all documentation is received by PCS, the application will be reviewed; if approved, PCS will notify the
applicant and assign an official Massachusetts registration number within ten (10) business days from the date that PCS
received the application. The Board will issue the official registration card within four to six weeks of registration
number assignment.
Application Fee
$150.00—Forms of Payment include: Visa, MasterCard, Discover or Money Order (made payable to PCS); see
attached Payment Form. Fees submitted cannot be refunded or transferred.
Contact Information
Applicants may contact PCS with questions regarding registration, or to inquire about application status by calling toll-
free (877) 887-9727 (8:00am-4:30pm CST) or email techlicen[email protected].
Application Materials must be submitted to:
Professional Credential Services
Attn: Pharmacy Coordinator
P.O. Box 198788, Nashville, TN 37219-8689
Massachusetts Board of
Registration in Pharmacy
Pharmacy Technician
Registration Application
Requirement for Social Security Number
The Massachusetts Board of Registration in Pharmacy Staff (Board) wishes to inform applicants that a social security
number (SSN) is required in order to obtain any professional pharmacy license, including that of a pharmacy intern or
pharmacist.
As mandated by Massachusetts law, the Board requires license applicants to submit a valid SSN as a condition of issuing or
renewing the license. M.G.L. c. 30A, § 13A.
The Board recognizes an exception to this rule for issuing initial licenses to foreign applicants not physically present in the
United States, and individuals whose visa for entry is related to employment involving a professional license. See 8 U.S.C. §
1621.
Once the license has been issued, license holders must obtain and submit a valid SSN as a condition of license renewal.
1
P.O. Box 198788
Nashville, TN 37219
All Pharmacy Technicians working in the Commonwealth of Massachusetts must complete this form and be registered
with the Board of Registration in Pharmacy prior to working in a Pharmacy as a Pharmacy Technician.
SOCIAL SECURITY NUMBER (SSN) |___׀___׀___| - |___׀___| - |___׀___׀___׀___|
First Name Middle Name Last Name Suffix/Other/Maiden
MOTHER’S MAIDEN NAME
FEMALE
MALE
DATE OF BIRTH |__׀__|__׀__|__׀__| CITY/STATE/COUNTRY OF BIRTH
HEIGHT (FT) (IN) WEIGHT (LBS) EYE COLOR
Home Address
Street Address or P.O. Box
City State ZIP Code
Telephone Number Fax Number Email Address
Name of High School City/State/Country of High School
Did you earn: (indicate one) Diploma
Graduation Date: _________________
mm/dd/yy
GED
Graduation Date: _________________
mm/dd/yy
Please complete one of the following categories:
1) Certified Applicants
Certification program for pharmacy technicians
Please indicate one:
EXCPT
PTCB
Certificate Number ________________________________
Date of Examination: ______________________________
Month/Day/Year
Certification Status: Current
Expired
Certified applicants MUST provide a copy of their current PTCB/EXCPT Certification Registration.
A. Biographical Information.
Provide all information as
requested. Applications are not
considered complete until all
requested information is provided.
* Social security number is
MANDATORY, pursuant to
MGL c. 62C, s. 47A. The Dept.
of Revenue will use your social
security number to determine if
you are in compliance with
Commonwealth child support
laws. If you are not entitled to a
U.S. social security number, you
must provide an Affidavit in
Support of Registration.
Thereafter, should you be issued a
social security number, you must
provide such number to the
Board.
B. Academic and Professional
Credentials. Applicants should
review registration requirements
at 247 CMR 8.02 or 247 CMR
8.04 on-line at:
www.mass.gov/dph/boards.ph
Massachusetts Board of
Registration in Pharmacy
Pharmacy Technician
Registration Application
2
2) Non-Certified Applicants
Have you passed a Board-approved Pharmacy Technician Assessment exam? Yes
No
Date of Examination: _______________ Score: _______________ (min. passing score of 75% required)
Month/Day/Year
Location of Examination: ________________________________________________________
Administered by (employer): _____________________________________________________
Please indicate which of the following requirements you have completed:
A minimum of 500 hours of employment as a pharmacy technician trainee
A Board-approved pharmacy technician training program
Verification of experience must be provided by employer on the attached Employer Verification Form.
Have you ever been registered as a Pharmacy Technician in another state or U.S. jurisdiction?
Yes
No
If yes, please complete the following:
State
License
Number
Date
Licensed
Current
Lapsed
Revoked or
Suspended
Probation
If you are registered as a Pharmacy Technician in another state, you must obtain a letter of verification of
licensure from each state, either current or expired. It must be in letterform and on letterhead of the board
where registered. A copy of your registration card is not acceptable.
1. Has any disciplinary action been taken against you by a licensing or
Yes
No
certification board located in the United States or any country or foreign
jurisdiction?
2. Are you the subject of pending disciplinary action by any licensing or
Yes
No
certification board located in the United States or any country or foreign
jurisdiction?
3. Have you voluntarily surrendered or resigned a professional license to a
Yes
No
licensing or certification board in the United States or any country or
foreign jurisdiction?
4. Have you ever applied for and been denied a professional license in
Yes
No
the United States or any country or foreign jurisdiction?
5. Have you been arrested, charged, arraigned, indicted, prosecuted,
Yes
No
convicted or been the subject of any investigation or any court proceeding in
relation to any felony or misdemeanor charge? If YES, please attach a
typewritten 8 ½” by 11” sheet(s) of paper which provides dates and details
describing the circumstances related to the matters on the matter(s); provide
certified copies of court documents of any convictions (defined as any plea
that is accepted by a court); and complete a Criminal Offender Record
Information Request (CORI) Form (available at pcshq.com).
(Note: Conviction of a crime does not necessarily bar registration; however, failure to disclose may
result in denial of application or other disciplinary action by the Board.)
B. Academic and Professional
Credentials. Applicants should
review registration requirements
at 247 CMR 8.02 or 247 CMR
8.04 on-line at:
www.mass.gov/dph/boards.ph/.
C. This section is applicable to
persons who hold or held
registration as a Pharmacy
Technician issued by another
state or US. jurisdiction. List all
states in which you hold or held a
license.
D. Questions.
Answer each of the
questions listed. If you
answered yes to any, please
attach a personal statement
of explanation. All questions
must be answered. A
certified copy of any
conviction (No. 5) must also
be included with your
personal statement.
3
By my signature below, I certify under the pains and penalties of perjury, that:
1. I am the applicant named in this application and pictured in the attached photograph.
2. The information that I have provided pursuant to this application is truthful and
accurate. I understand that the failure to provide accurate information may be grounds
for the Board of Registration in Pharmacy to deny this application and/or revoke the
right to function as a Pharmacy Technician, in accordance with Massachusetts law.
3. I understand that the Massachusetts Board of Registration in Pharmacy has been
certified by the Criminal History Systems Board for access to conviction and pending
criminal case data. As an applicant for initial licensure and/or registration by
examination or by reciprocity, I understand that a criminal record check will be
conducted for conviction and pending criminal case information only and that it will not
necessarily disqualify me.
4. I agree that in the event my examination papers are lost, or if the examination is not held
for any reason, any claim that I may have will be limited to the examination fee paid by
me.
5. I understand that this application is void if requirements are not met within one year
from the date of receipt. I also understand that the fees are non-refundable and non-
transferrable.
6. I am responsible for reading, understanding, and abiding by the rules and regulations of
the Board of Registration in Pharmacy; statutes pertaining to the practice of pharmacy
(M.G.L. c.112, ss. 24-42 and c. 94C); and 247CMR (Commonwealth of Massachusetts
Regulations).
7. Pursuant to M.G.L. c. 119, s. 51A and M.G.L. c. 112, s. 1A, I understand my obligation
to report the abuse or neglect of children.
8. Pursuant to M.G.L. c. 62C, s. 49A, to the best of knowledge and belief, I have filed all
Massachusetts state income tax returns and paid all taxes required by law.
Applicant Signature (signed in the presence of a Notary Public) Date
Print Name of Notary Public
Signature of Notary Public
My commission expires on:
Month/Day/Year
E. Affidavit.
Application must be signed in the
presence of a notary public.
Application will not be processed
unless signed by the applicant and
notarized.
Attach
2 x 2 Photo of
Candidate
Affix
Notary
Seal
4
P.O. Box 198788
Nashville, TN 37219
Pharmacy Technician Application Fee - $150
Please check form of payment below:
Money Order
Please make it payable to “PCS” for the total amount of the application fee. Do Not staple
your payment to this form.
Or
Credit Card
Authorized payment amount: $ ______ Please check one: Visa MasterCard Discover
Card Number: ___________-___________-___________-___________ Exp: /
Print name as it appears on account:
Authorized Signature:
Return this payment form with Application/Scheduling Form.
NOTE: this document will be shredded after it has been processed.
Payment Form
Massachusetts Board of
Registration in Pharmacy
Pharmacy Technician
Registration Application
5
P.O. Box 198788
Nashville, TN 37219
Employer Verification of Experience and Examination
This form is to be completed by the Pharmacist Employer for Non-Certified Applicants.
Massachusetts Board of
Registration in Pharmacy
Pharmacy Technician
Registration Application
Please type or print using blue or black ink only.
__________________________________________________________________________________________
First Name Middle Name Last Name Other/Maiden
__________________________________________________________________________________________
Date of Birth Social Security Number or Affidavit in Support of Registration
__________________________________________________________________________________________
Pharmacist’s Name State License No. License Expiration Date
__________________________________________________________________________________________
Pharmacy Name
__________________________________________________________________________________________
Pharmacy Location: Street Address
__________________________________________________________________________________________
City State ZIP Code
__________________________________________________________________________________________
Email Address Telephone Number
1) Is the applicant named above currently working under your supervision?
Yes
No
2) Training / Experience
A.) Successfully completed hours of supervised experience as a pharmacy technician trainee
Yes
No
List the number of hours ________________
B.) Successfully completed a Board-approved training program
Yes
No
Identify the Board-approved training: ____________________________
3.) Did the applicant pass a Board-approved pharmacy technician assessment examination?
Yes
No
Date of examination: ________________ Score: ___________ (min. passing score of 75% required)
Administered by (employers name): __________________________________
By my signature below, I hereby certify, under the penalties of perjury, that the information above is true and accurate.
_________________________________________________________ ____________________
Signature of Pharmacist Date
A. Applicant Information.
Provide information of Pharmacy
Technician who is to be
registered.
B. Pharmacist Information.
This section is to be completed
by the Pharmacist Employer.
Applicant Does Not Complete
This Section.
Supervising Pharmacist must
complete this section on behalf
of applicant prior to submitting
form to PCS.
