Refer to the Pharmacy Technology Program website under How To Apply to make sure you have completed the application process thoroughly and accurately. Applicants who submit incomplete applications or who are missing any required documents will automatically be ineligible. Your application must be completed within 2 hours. You will not be able to save and return to make any changes or submit at a later time. Only one application submission per application cycle is allowed. Student First Name Student Last Name Student Middle Name Previous Maiden Name(s): (if any) Street Address City State - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Phone My Canyons Email My Canyons Email Verify My Canyons Email Do you have a Social Security #? Yes No COC STUDENT ID # Have you ever attended another Pharmacy Technology Program or any program which included placement in a clinical facility? Yes No If yes, type of program, name of school, dates of attendance? Did you complete the program? Yes No If no, are you eligible to return to this program? Yes No Are you a U.S. citizen? Yes No If no, are you in the U.S. as a Permanent Resident? Yes No If yes, Document # If no, are you in the U.S. on a Visa? Yes No If yes, type of Visa Visa# Are you lawfully eligible to work in the U.S.? Yes No Check all that apply High School Completion Must attach copy of high school transcript, OR copy of diploma, OR copy of GED certificate. If from foreign country, must provide translation. Month/Year of High School Completion or GED My signature is mandated and indicates that I have completed all sections truthfully. I understand that should I be admitted to the Pharmacy Technology Program, any falsification, misrepresentation, or omissions of facts are sufficient reason for dismissal upon discovery at any time during the pharmacy technology program. I authorize the release of College of the Canyons transcripts to the COC Health Professions Department when I apply and each semester that I am a part of the program. I will provide further documentation if requested. Student Signature Demographic Information This information is confidential and is gathered for statistical purposes only. The information provided below, or the failure to provide the information below, will in no way affect your ability to enter the pharmacy technology program. Gender Male Female Other Ethnicity White (All persons having origins in Europe, North Africa or the Middle East and not of Hispanic origin) Hispanic (All persons of Chicano, Mexican, Puerto Rican, Cuban, Central/South American, or other Spanish culture origin regardless of race) American Indian (All persons having origins in the original peoples of North America and who maintain cultural identification by virtue of tribal association or community recognition) Asian/Pacific Islander (All persons having origins in the Far East, Southeast Asia, the Indian Subcontinent, or Pacific Islands, including the Philippine Islands) Black (All persons having origins in any of the black racial groups of Africa and not Hispanic in origin) Other (please describe) Ethnicity Other EducationHighest level of education obtained to date High School Diploma or GED Associate Degree Baccalaureate Degree Master's Degree Doctoral Degree No Degree Age Language spoken in the Home Persons with Disabilities It is your responsibility to notify the Disabled Students Programs and Services office at the College with verified documentation from a health or learning specialist in order to receive reasonable accommodation. Non Discrimination Policy The School of Health Professions does not discriminate on the basis of ethnic group identity, religion, sex, age, color, national origin, marital status, sexual orientation, veteran's status, mental disability or physical disability including persons with AIDS/ARC/HIV in any of its policies, procedures, or practices. This non-discrimination statement covers admission and access to, and treatment and employment in the programs, services and activities. File Uploads Please attach the applicable documents needed to complete your Pharmacy Technology Application as .pdf FILES ONLY. High School Diploma or High School Transcripts or GED Certificate (Official transcripts will be required for state licensing). If high school completion is from a foreign country, you must have the document translated into English. The translation does not have to be an officially sealed transcript. The following are examples of viable translation services: Academic Credentials Evaluation Institute (ACEI) Academic and Professional International Evaluations, Inc. (A.P.I.E.) Signed Technical Standards Self Reporting Tool (SRT) for English and Math Assessments Personal Statement File Uploads Maximum 10 files.15 MB limit.Allowed types: pdf. Leave this field blank