Name *Phone *Email Address *Are you male or female? *MaleFemalePlease only select what's listed on your birth certificate.Address *City *State *ZIP *Yes, I agree *I hereby certify that I’m 18 years of age and I have a high school diploma/GED or equivalent, valid ID, and agree to provide a copy of each item to the school when requested.Birthdate *Enter your school’s address and year where you received your HS diploma or GED equivalent. *Emergency Contact *Please list the phone number and the name of your contact person. Example: Jane Doe: (602) 345-0700Social Security Number, Drivers License, or State ID (please include the state where your drivers license or state ID was issued) (EXAMPLE: AZ, D12345678 or SS: 000-00-0000) *Please list only one of the above IDs. If you don’t have a Social Security number you will need a Valid ID: State ID, Arizona Drivers License, or Arizona State ID to attend the program.Fingerprint Clearance Card/Health and Safety Requirements *I realize that I must obtain a Fingerprint Clearance Card and be capable of meeting all of the Health and Safety requirements prior to the start date of the externship. View Agreement.I understand that most of this program is offered online and the interactions (or communication) between the student and instructor will be conducted primarily via text, e-mail or telephone? *Do you confirm that you have a computer with webcam capability, smart phone, high speed internet, and the proper equipment to receive incoming calls or e-mails to complete the assignments in the program?How did you hear about us? *Facebook/InstagramGoogle/YoutubeTicTokPTCB WebsiteArizona@workBulletin Board/Sign or Business CardA Friend or AcquaintanceRadioDo you require financial assistance to help with the cost of your tuition and would you be interested in receiving a scholarship if chosen? *YesNoYou may be eligible to receive a scholarship or financial assistance if you replied yes to this question.Do you require any special accommodations that is qualified under the ADA to complete this program? *YesNoAVPTS (Arizona’s Virtual Pharmacy Tech School) will use the information you provided to conduct a background check to determine the validity of your application. *A check mark in the box will have the same force an effect as a hand written signature.I have reviewed the Course Catalog and I agree to all of the the terms and conditions set forth in Arizona’s Virtual Pharmacy Tech School Course Catalog. *A check mark in the box will have the same force an effect as a hand written signature. View Agreement.I have reviewed the Enrollment Agreement and I agree to the terms and conditions set forth in this agreement. *The Enrollment Agreement will be populated with the information that was provided in this application and will serve as your official agreement after approval (A check mark in the box will have the same force an effect as a hand written signature). View agreementPayment:Course registration fee $15. pay with Paypal.Send MessageSave as Draft
