Application Form

Admission Application for Pharmacy Technician Training Program.

If paying by check or money order, please complete this form and mail payment to:

Pharmacy Technician Enterprises, Inc.,
601 Portion Road
Suite 208
Lake Ronkonkoma, NY 11779


Print Application (Word Document)


If paying by credit card, please complete the following electronic application. The process is not complete until your credit card has been successfully charged.

Check desired Session IV 2010

Session IV 2010

Check desired Session V 2010

Session V 2010

Check desired Session VI 2010

Session VI 2010

First Name:

Last Name:

Street Address:

City:

State Abreviation:

Zip:

Home Tel. No.:

Work Tel. No.:

Cellphone No.:

Email Address:

Date of Birth:

Last 4 digits of Social Security No.:

Name of High School or Secondary School attended:

Year Graduated:

Lab Coat Chest Size (inches):

Are you interested in a Payment Plan:

Yes No

 

 



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