Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT 05620-3402 Board of Pharmacy Renewal Clerk (802) 828-1505 www.vtprofessionals.org Pharmacist & Pharmacist Preceptor Renewal/Reinstatement Application Current Expiration 07/31/2015 You Must Complete The Information Below: Renewal Period Covering 08/01/2015 through 07/31/2017 Renewal Application Fee $100.00 n Refundable Processing Fee Checks Payable to: Vermont Secretary of State For Office Use Only License #: ---- Name: Address: City/State/ZIP: Country: Directions: To renew you must enclose a check or money order in the amount indicated, payable in US funds from a bank with a United States affiliate to Vermont Secretary of State. The renewal fee is non-refundable. If the completed renewal application, along with all supporting documentation, is not received in the Office by the expiration date, you will be required to pay an additional penalty in addition to the renewal fee. Call the Office for a calculation of the penalty before submitting this renewal application. Reminder: You may not practice your licensed profession without an active license. Faxes not accepted. Has your name changed since you last renewed, or were originally licensed? (Circle One) If, you must attach a copy of your marriage license, civil union license or section of divorce decree granting you the authority to change your name. Section A: Demographic Information If your mailing address has changed, indicate your new address in the box to the right. te: It is unprofessional conduct for a licensee to fail to notify the Secretary of State s Office of a change of name or address within thirty (30) days (3 V.S.A. 129a(a)(14)). P.O. Box Street/Apt # City/State/Zip Country Street/Apt # If your 911 address has changed, indicate your new address in the box to the right. Suite/Department/Floor City/State/Zip Phone: ( ) - Cell Phone: ( ) - E-Mail Address: Date of Birth (MM/DD/YYYY) Gender: (Circle One) DEA # / / Male Female
Section B: Vermont Mandatory Good Standing Declarations CHILD SUPPORT: Child Support Orders, 15 V.S.A. 795(b): Good standing for child support is defined by 15 V.S.A. 795(d). You must check the appropriate box. As of the date of this application: I am not subject to a child support order. I am subject to a child support order and I am in good standing or in full compliance with a plan to pay any and all child support. I am subject to a child support order and I am NOT in good standing or in full compliance with a plan to pay any and all child support. Please contact the Office of Child Support at (802) 241-2319. OCS must report your compliance to this office before you may be issued a license. TAXES: Taxes Due to the State of Vermont, 32 V.S.A. 3113(b): Good Standing for taxes due is defined by 32 V.S.A. 3113(g). You must check the appropriate box. As of the date of this application: I am in good standing with respect to, or in full compliance with a plan to pay any and all taxes due to the Vermont Department of Taxes. I am NOT in good standing * with respect to or in full compliance with a plan to pay any and all taxes due to the Vermont Department of Taxes. Please contact the Vermont Department of Taxes at (802) 828-2515 for more information. The Tax Department must report your compliance to this office before you may be issued a license. DISTRICT COURT FINES/JUDICIAL BUREAU: Court judgments for fines or penalties, 4 V.S.A. 1110(b): Good standing for court judgments is defined by 4 V.S.A. 1110(c). You must check the appropriate box. As of the date of this application: I have no unpaid judgments issued by the judicial bureau or criminal division of the superior court for fines or penalties for a violation or criminal offense. I am in good standing with respect to any unpaid judgment issued by the judicial bureau or criminal division of the superior court for fines or penalties for a violation or criminal offense. I am NOT in good standing with respect to any unpaid judgment issued by the judicial bureau or criminal division of the superior court for fines or penalties for a violation or criminal offense. You must provide this office documentation of compliance before you may be issued a license. RESTITUTION ORDERS: Unpaid Judgments, 13 V.S.A. 7043a: Good standing for restitution orders is defined by 13 V.S.A. 7043a(c). You must check the appropriate box. As of the date of this application: I have no restitution order. I am in good standing with respect to any restitution order. I am NOT in good standing with respect to any restitution order. You must provide this office documentation of compliance before you may be issued a license.
Section C: Vermont Mandatory Credential and Fitness Questions Please circle or for each of these questions. If the answer is, follow the provided instructions. Since your license was last renewed (or since it was issued if within the last two years): Has Vermont or any other state, federal authority, or any jurisdiction (US or elsewhere) denied an application by you for a license, certificate, or registration to practice a profession or occupation? If, you must attach a copy of the order or official notification of the action(s). Since your license was last renewed (or since it was issued if within the last two years): Has Vermont or any other state, federal authority, or any jurisdiction (US or elsewhere) taken any disciplinary action (restricted, suspended, revocation or conditioned) against a license, certificate, or registration that you hold or held in any profession or occupation? If, you must provide a copy of the order or official notification of the action. Since your license was last renewed (or since it was issued if within the last two years): Have you surrendered a license, certificate, or registration to a licensing authority in Vermont or any other state, federal authority or other jurisdiction (US or elsewhere)? If, you must provide a detailed written explanation and copies of any applicable documentation. Are you currently under investigation by a licensing authority in Vermont or any other state, federal authority or other jurisdiction (US or elsewhere)? If, you must provide a detailed written explanation and a copy of any available information from the licensing authority. Since your license was last renewed (or since it was issued if within the last two years): Have you been convicted of a crime other than a minor traffic violation? Driving While Intoxicated and Driving Under the Influence are not minor traffic violations. If, you must provide a detailed written explanation and attach the official court documents, (i.e., the affidavit of probable cause, the information and/or the docket report). Do you have any criminal charges pending against you in Vermont or any other jurisdiction (US or elsewhere)? If, you must provide a detailed written explanation and attach a copy of the charging documents. Vermont law requires that you report to the Office of Professional Regulation a felony conviction or any conviction of a crime related to the practice of your profession within 30 days. 3 V.S.A. 129a(a)(11). The answers to the following questions are not subject to public disclosure: Do you have a physical or mental condition or disorder which in any way impairs or limits your ability to practice this profession with reasonable skill and safety? If, you must have your health care provider submit a detailed statement explaining how you are able to practice safely. Does your use of alcohol, substances, or prescription medications impair or limit your ability to practice this profession with reasonable skill and safety? If, you must provide a detailed written explanation. Are you currently addicted to or in any way dependent on alcohol or habit forming drugs? If, you must provide a detailed written explanation. Name (print): License Number: 3
Section D: Continuing Education Requirement You are not required to send any supporting documentation with this form if you renew by the license expiration date. The Office of Professional Regulation reserves the right to verify information submitted by applicants for renewal and conducts a random audit of CE for each profession. You must retain all documentation for seven years after completion of the program/course. Please complete the Continuing Education Record on the next page. If you are renewing more than 30 days late, you must submit all CE documents with your completed renewal form. Board of Pharmacy Administrative Rules Part 3 3.2 Continuing Pharmacy Education (CPE) Requirements The licensee must complete a total of 30 CPE hours per renewal period. A minimum of ten hours shall be obtained during participation in live programs (didactic sessions). Continuing pharmacy education participation must be reported every two-year renewal period. For newly-licensed pharmacists, see Rule 3.11 below. 3.11 Newly Licensed Pharmacists For applicants granted an initial license to practice by the Board, accumulation of CPE s shall commence on the opening date of the first biennial renewal period following receiving initial Vermont licensure. Continuing Education Requirement (Check the box that applies to your license.) My Pharmacist license was first issued in Vermont on or after 08/01/2013; therefore I do not have to complete Continuing Education for this renewal cycle (0 hours). My Pharmacist license was first issued in Vermont prior to 08/01/2013; and I have completed 30 hours of continuing education. (Ten hours of which must be live (didactic) sessions.) I have NOT met the continuing education requirement (CE extensions may be granted in exceptional circumstances for good cause shown upon written request with a completed renewal form and fee submitted prior to the expiration date.) Name (print): License Number: 4
Itemize the education courses taken over the past two years (submit additional sheets if more space is needed) TITLE & CONTENT OF PROGRAM SPONSORING ORGANIZATION # OF CREDITS/HOURS AWARDED DATES TOTAL # OF CREDITS/HOURS: Name (print): License Number: 5
Section E: Expired License If this is a late renewal, have you been practicing in Vermont since your license expired? If, please attach a description of the extent of your practice since your license expired. N/A Section F: Affirmation Statement of Applicant I certify, under the pains and penalties of perjury, that all information I have provided in this application is true and accurate. I understand that furnishing false information may constitute unprofessional conduct and result in the denial of my application for renewal or further disciplinary action. The maximum penalty for perjury is fifteen years in prison and/or a $10,000 fine. (13 V.S.A. 2901) Signature of Applicant **(REQUIRED)** Signature Date (MM/DD/YYYY) Print Name: License # ---- Name (print): License Number: 6
Office of Professional Regulation Vermont Secretary of State Attn: Renewal Clerk 89 Main St. 3 rd Floor Montpelier, VT 05620-3402 Phone: (802) 828-1505 Fax: (802) 828-2465 www.vtprofessionals.org Vermont Office of Professional Regulation Survey (optional) 2015 Renewal License #: Name: ---- 1. Would you be willing to serve as a Board/Advisor member of the Board/Commission/Advisory panel for your profession? If you answer "," submit a letter of intent and resume to the Office for consideration. 2. Would you be willing to serve as an Ad Hoc member of the Board/Commission/Advisory panel for your profession? If you answer "," submit a letter of intent and resume to the Office for consideration. 3. Would you be willing to serve as an Expert Witness for a licensing case(s) associated with your profession? If you answered to the question above, what is your area of expertise? Name (print): License Number: 7
25231 First Name. VERMONT DEPARTMENT OF HEALTH Census of Pharmacists 2015 This census is designed to assess the distribution of Pharmacists throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) 863-7300 or 1-800-869-2871. Thank you for your cooperation. Vermont License Number (example: 033.0012345) 0 3 3 Middle Name (Please print legibly using a dark blue or black pen and uppercase letters; fill in small check ovals entirely) 1 Last Name 1. Gender: Male Female 2. Are you Hispanic or Latino/a? (check all that apply) Mexican or Mexican American Puerto Rican Cuban or Cuban American Other Hispanic, Latin, or Spanish Origin t hispanic Choose not to respond 4. In which state did you graduate from high school or complete your GED? (use 2-letter code for state, CC for Canada, XX for other foreign countries) 5. Enter the two-letter code for the state where you completed your highest degree related to this license: (use CC for Canada, XX for other foreign countries) Name of other foreign country: Birthdate (mm-dd-yyyy) - - 3. Race? (check all that apply) American Indian or Alaska Native Asian Black or African American Native Hawaiian or Pacific Islander White Other Choose not to respond 8. For each of the following educational experiences that you have completed, please indicate the year in which you completed the experience: Bachelor of Pharmacy PharmD PhD MS, MBA, MA, MPH, etc Residency 6. At which institution did you receive your pharmacist education? Fellowship BPS Certification Program 7. Do you have an NPI number? If yes, please enter your NPI number below: State Clinical Pharmacist Recognition Other Certification Program Other Please continue on next page. Thank you. 25231
25231 Vermont License Number 0 3 3.. VERMONT DEPARTMENT OF HEALTH Census of Pharmacists 2015 This census is designed to assess the distribution of Pharmacists throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) 863-7300 or 1-800-869-2871. Thank you for your cooperation. (Please re-enter your license number for scanning purposes) 2 9. In what year did you receive your first Pharmacy license? 10. In what state(s) do you hold an active license? State (postal) abbreviation(s): 11. What is your employment status? (Select ONE) Practicing as a pharmacist, full-time Practicing as a pharmacist only, part-time Practicing as a pharmacist part-time, employed in a pharmacy-related field or position part-time Practicing as a pharmacist part-time, employed in a non-pharmacy related field or position part-time Employed in a pharmacy-related field or position, not practicing as a pharmacist Retired, but still working in pharmacy or employed part-time as a pharmacist Retired, do not practice pharmacy at all, still working or employed part-time. Retired, do not work Unemployed (seeking employment) Unemployed (not seeking employment) Employed in a career not related to pharmacy 12. Do you currently provide pharmacist services in Vermont as a Pharmacist? (If only remotely from outside Vermont, answer "no") 13. If no, do you plan to start (or resume) pharmacist services in Vermont within the next 12 months? * IF you are NOT providing direct patient care IN VERMONT as a Pharmacist, PLEASE STOP HERE AND RETURN SURVEY 14. What are your employment plans for the next 12 months regarding pharmacist services in Vermont? 15. In what year did you first work as a pharmacist in Vermont? Increase hours in patient care Decrease hours in patient care Seek a non-clinical job Retire Continue as you are Unknown 16. Are you able to provide pharmacy services to clients/patients in a language other than English? Please continue on next page. Thank you. 25231
25231 Vermont License Number 0 3 3. VERMONT DEPARTMENT OF HEALTH Census of Pharmacists 2015 This census is designed to assess the distribution of Pharmacists throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) 863-7300 or 1-800-869-2871. Thank you for your cooperation. (Please re-enter your license number for scanning purposes) Please enter site information FOR EACH LOCATION where you provide direct patient care IN VERMONT. If you provide care at two locations in the same town, please enter each as a separate site. SITE ONE (principal site) - TOWN for the Vermont location where you work, not a mailing address: 3 Practice Name and Street Address: ZIP code for the Vermont location where you work: - Which best describes the type of setting that most closely corresponds to this practice location? (please choose ONE): Independent Community Pharmacy (1-3 stores) Nursing Home/Long Term Care Small Chain Community Pharmacy (4-9 stores) Home Health/Infusion Large Chain Community Pharmacy (10+ stores) Pharmacy Benefit Administration (e.g. PBM) Mass Merchandiser (i.e. Big Box store) School-based health service Supermarket Pharmacy Academic Institution Clinic-Based Pharmacy Occupational health Mail Service Pharmacy Telepharmacy Health Center (CHC/FQHC/FQHC look-alike) Consultant Pharmacist Federal Hospital/Health System - Inpatient Ambulatory care office-based practice Federal Hospital/Health System - Outpatient Ambulatory care community pharmacy-based practice n-gov't Hospital/Health System - Inpatient Regulatory Practice, Federal Government n-gov't Hospital/Health System - Outpatient Regulatory Practice, State Government n-gov't Hospital/Health System - Other Other - please specify: Please indicate the average number of hours you spent per working week at this site in each of the following activities: Medication Dispensing Business/Organization Management Education Patient care services Research Other During how many weeks in a year do you work at this site as a pharmacist? (48 weeks is considered "year round") Weeks Per Year Which of the following best describes your current employment arrangement at this site: Owner Self employed/consultant Salaried employee Hourly employee Relief pharmacist Other - please specify: If you have a second practice site, continue on the next page. If you only have one practice site, stop here, but please return all 4 pages. 25231
25231 VERMONT DEPARTMENT OF HEALTH Census of Pharmacists 2015 This census is designed to assess the distribution of Pharmacists throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) 863-7300 or 1-800-869-2871. Thank you for your cooperation. Vermont License Number 0 3 3 (Please re-enter your license number for scanning purposes).. SITE TWO - TOWN for the Vermont location where you work, not a mailing address: 4 Practice Name and Street Address: ZIP code for the Vermont location where you work: - Which best describes the type of setting that most closely corresponds to this practice location? (please choose ONE): Independent Community Pharmacy (1-3 stores) Small Chain Community Pharmacy (4-9 stores) Large Chain Community Pharmacy (10+ stores) Mass Merchandiser (i.e. Big Box store) Supermarket Pharmacy Clinic-Based Pharmacy Mail Service Pharmacy Health Center (CHC/FQHC/FQHC look-alike) Federal Hospital/Health System - Inpatient Federal Hospital/Health System - Outpatient n-gov't Hospital/Health System - Inpatient n-gov't Hospital/Health System - Outpatient n-gov't Hospital/Health System - Other Nursing Home/Long Term Care Home Health/Infusion Pharmacy Benefit Administration (e.g. PBM) School-based health service Academic Institution Occupational health Telepharmacy Consultant Pharmacist Ambulatory care office-based practice Ambulatory care community pharmacy-based practice Regulatory Practice, Federal Government Regulatory Practice, State Government Other - please specify: Please indicate the average number of hours you spent per working week at this site in each of the following activities: Medication Dispensing Business/Organization Management Education Patient care services Research Other During how many weeks in a year do you work at this site as a pharmacist? (48 weeks is considered "year round") Weeks Per Year Which of the following best describes your current employment arrangement at this site: Owner Self employed/consultant Salaried employee Hourly employee Relief pharmacist Other (please specify) If you work at more than two sites please check bubble and describe briefly in margin. Thank you. 25231