This application is to certify that you meet the eligibility requirements for the CPhT-Adv credential.

Please provide up to two weeks for review and processing.

Applicant Details

First Name *

Last Name *

Address *

Address 2

City *

State/Province *

Zip/Postal Code *

Daytime Phone *

Email Address *

Eligibility Requirements

Candidates must:

1. Be an active CPhT (through either NHA or PTCB)
          AND
2. Have the following specialty certificates/certifications:
      Option 1. Completion of any four assessment-based specialty certificates*, OR
      Option 2. Completion of any three assessment-based specialty certificates* + one of the following certifications (BCSCPT, BCNCPT or CSPT).
          AND
3. A minimum of 2 years of supervised pharmacy experience.

*BPTS will recognize PTCB Specialty Certificates, however candidates must have earned at least one specialty certificate from BPTS.

1. Active CPhT Certification

CPhT Certification # *

Issued By: *

NHA

PTCB

2. Specialty Certificates/Certifications

Credential #1 *

Issued By: *

BPTS

PTCB

Credential #2 *

Issued By: *

BPTS

PTCB

Credential #3 *

Issued By: *

BPTS

PTCB

Credential #4 *

Issued By: *

BPTS

PTCB

3. Employment

Candidates may provide information on up to 4 employers per form.

NOTE: You ONLY need to document the required amount experience (2 years or 2,000 hours) – not your full employment data. If additional documentation is required, please contact support@bpts.org

Employer/Company Name:

Start Date (MM/YY)

End Date (MM/YY)

Presently Employed Here *

Yes

No

Supervisor/PIC First Name:

Supervisor/PIC Last Name:

Supervisor/PIC License State/Number

Supervisor/PIC Phone Number:

Supervisor/PIC E-mail:

Experience at this employer:

2 years / 2,000 hours or more

Other _______ hours Other _______ hours

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Continue, if necessary:

Employer/Company Name:

Start Date (MM/YY)

End Date (MM/YY)

Presently Employed Here *

Yes

No

Supervisor/PIC First Name:

Supervisor/PIC Last Name:

Supervisor/PIC License State/Number

Supervisor/PIC Phone Number:

Supervisor/PIC E-mail:

Experience at this employer:

2 years / 2,000 hours or more

Other _______ hours Other _______ hours

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Continue, if necessary:

Employer/Company Name:

Start Date (MM/YY)

End Date (MM/YY)

Presently Employed Here *

Yes

No

Supervisor/PIC First Name:

Supervisor/PIC Last Name:

Supervisor/PIC License State/Number

Supervisor/PIC Phone Number:

Supervisor/PIC E-mail:

Experience at this employer:

2 years / 2,000 hours or more

Other _______ hours Other _______ hours

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Continue, if necessary:

Employer/Company Name:

Start Date (MM/YY)

End Date (MM/YY)

Presently Employed Here *

Yes

No

Supervisor/PIC First Name:

Supervisor/PIC Last Name:

Supervisor/PIC License State/Number

Supervisor/PIC Phone Number:

Supervisor/PIC E-mail:

Experience at this employer:

2 years / 2,000 hours or more

Other _______ hours Other _______ hours

Release Authorization
*

I hereby authorize the employers listed above to release any necessary information to BPTS to verify my employment.