GUAM BOARD OF EXAMINERS FOR PHARMACY

GUAM BOARD OF EXAMINERS FOR PHARMACYDepartment of Public Health & Social Services194 Hernan Cortez Ave., Terlaje Bldg. Ste 213A Hagatña, Guam, 96910-5052CHECKLIST – PHARMACIST BY ENDORSEMENTNAME OF APPLICANT:DATE APPLICATION REC’D:1. Signed and notarized application [GBEP-1].2. One (1) 2x2 photographs taken within the last 3 months.3. Application fee [GBEP-7].4. Notarized affidavit of the applicant of a change of name, if applicable.5. Verification of License (check verification received):Home State [GBEP-6]National Association of Boards of Pharmacy (NABP)6. Three (3) letters of recommendation from professional acquaintances (not older than 2 yearspreceding date of application).7. Passing score on the Guam Jurisprudence Examination ****************************************** ************* FOR BOARD USE ONLY **BOARD MEMBERSIGNATUREBOARDACTION APPROVED DISAPPROVED APPROVED DISAPPROVED APPROVED DISAPPROVEDDATECOMMENTS

GUAM BOARD OF EXAMINERS FOR PHARMACYDepartment of Public Health & Social Services194 Hernan Cortez Ave., Terlaje Bldg. Ste 213A Hagatña, Guam, 96910-5052REQUIREMENTS FOR PHARMACIST BY ENDORSEMENTThe following information is provided and guides you in the application procedures to practice pharmacy onGuam. If there are questions, you may contact the Board Secretary for assistance.Requirements for Licensure:1. Completed application – signed and notarized (GBEP-1).2. One (1) 2” x 2” photograph taken within the last (3) three months.3. Application fee (GBEP-7).4. At least 18 years of age.5. Verification of license from original State of Board of Licensure (GBEP-6).6. Three (3) letters of recommendation from professional acquaintances not older than two (2) yearspreceding date of application.7. Notarized affidavit of the applicant of a change of name, if applicable.8. Once approved by the Board, applicant must successfully pass the Guam Jurisprudence Examination.INSTRUCTIONS FOR FILING THE APPLICATION WITH THE BOARDIt is the responsibility of each applicant to ensure that the GBEP Secretary receives all necessary documents.The application is considered incomplete until all necessary documents, including recent photographs arepresented to the GBEP and all the applicable fees have been paid. In making application for licensure as apharmacist, the applicant authorizes the GBEP to verify any or all information contained in the application and/orseeks whatever additional information pertinent to the applicant’s qualifications or character that it may deemproper.

GUAM BOARD OF EXAMINERS FOR PHARMACYDepartment of Public Health & Social Services194 Hernan Cortez Ave., Terlaje Bldg. Ste 213A Hagatña, Guam, 96910-5052LICENSE APPLICATION FOR PHARMACIST BY ENDORSEMENTA. GENERAL INFORMATION:1. Type or print in ink.2. All forms must be filled completely by the applicant. Application fee should be made payable toTREASURER OF GUAM and is NON-REFUNDABLE.3. Return complete application form to the Guam Board of Examiners for Pharmacy at the aboveaddress. See RECORD OF PAYMENT form (GBEP-7) for applicable fees and instructions.B. IDENTIFICATION:Name:(Last)(First)(Middle Initial)Social Security No.:Gender: ( ) M ( ) FDate of Birth: Place of Birth:(City)(State)Permanent Address:Mailing Address:(Street or P.O. Box #)(City)(State)(Zip Code)Date applied: Work Phone: Home Phone:Email:C. EDUCATIONAL INFORMATION:EDUCATIONALBACKGROUND1.High School2.College/University3.Post GraduateTraining(Internship,Residency, etc.)NAME & ADDRESS OFSCHOOLDATE GRADUATEDDEGREE/CERTIFICATED. PROFESSIONAL INFORMATION:1. License Informationa. State/CountryLicensed:Date ofIssue:b. Has license ever been revoked, suspended or investigated? Yes(If yes, please explain on a separate sheet).ExpirationDate:No

GUAM BOARD OF EXAMINERS FOR PHARMACYDepartment of Public Health & Social Services194 Hernan Cortez Ave., Terlaje Bldg. Ste 213A Hagatña, Guam, 96910-50522. Professional Experience:FROMTOLOCATIONTYPE OF PRACTICEREASON FORDISCONTINUATION3. Member of the following professional associates:E. GRADUATES OF FOREIGN PHARMACY SCHOOLS:All graduates of foreign pharmacy schools shall first write and successfully pass the Foreign PharmacyGraduate Equivalency Examination (FPGEE), an examination administered by the Foreign PharmacyGraduate Examination Commission (FPGEC). The Board will verify this information. Please signpermission (GBEP-10).Date Taken:Score:F. AFFIDAVIT:TO BE SWORN TO BEFORE AN OFFICER AUTHORIZED TO ADMINISTER OATHS BY THEAPPLICANT WHO HAS COMPLETED THIS FORM, AND IS APPLYING FOR GUAMLICENSURE.SUBSCRIBE AND SWORN BEFORE METHIS DAY OF , 20SIGNATURENOTARY PUBLIC:MY COMMISSION EXPIRES:NOTARY PUBLIC SEAL

GUAM BOARD OF EXAMINERS FOR PHARMACYDepartment of Public Health & Social Services194 Hernan Cortez Ave., Terlaje Bldg. Ste 213A Hagatña, Guam, 96910-5052PHARMACIST ENDORSEMENT VERIFICATION FORMA. INSTRUCTIONS1. Please complete Part B of this form.2. Send one of these forms to your state of original licensure and to the State Board wherein you arecurrently licensed (include whatever processing fee the state may require).3. That State Board will return this form directly to the Guam Board of Examiners for Pharmacy at theabove address.B. PERSONAL IDENTIFICATION: TO BE COMPLETED BY APPLICANT1. NAME(Last)(First)(Middle)2. ADDRESS(Mailing Address)3. Social Security No.:Date of Birth:I hereby authorize the recipient of this request to provide the Guam Board of Examiners for Pharmacyinformation requested as per the checked box.C. TO BE COMPLETED BY THE LICENSING AUTHORITY1. Original Licensing State Boarda. Name of State Boardb. Original License Number Issued onc. License StatusActiveExpires onInactiveLapsedd. Name of Examinatione. Result of Examinationf. Was school approved/accredited when applicant graduates? ( ) Yes( ) NoCurrent Licensing State Boarda. Name of State Boardb. License Number Issued on Expires on2. Has this license ever been encumbered in anyway (revoked, suspended, surrendered, restricted, limitedor placed on probation)?( ) No( ) Yes (Please explain on reverse side)3. Certification:SealI hereby certify that the above information represents accuratelyon file with this agency, for the above named individual.SignatureTitleStateDate

GUAM BOARD OF EXAMINERS FOR PHARMACYDepartment of Public Health & Social Services194 Hernan Cortez Ave., Terlaje Bldg. Ste 213A Hagatña, Guam, 96910-5052RECORD OF iling Address:(Street or P.O. Box #)(City)Signature:(State)(Zip Code)DateVERIFICATION OF LICENSURE: Please print the complete name used on original license and your Social Security number.Name:SS#:FEE: Fee paid is NON-REFUNDABLE. Make all checks or money orders payable to TREASURER OF GUAM.Please check your st’s Licensure Application fee (charged once)Pharmacist’s License Renewal feeTemporary License feePharmacy Permit feePharmacy Permit Renewal feePharmacy Intern Application feePharmacy Intern Renewal feePharmacy Technician License feePharmacy Technician License Renewal feePenalty for late renewal of Pharmacy InternMiscellaneous permit fee (Wholesalers, Drug Outlets, etc.)Miscellaneous Permit RenewalPenalty for late renewal of Pharmacist’s licensePenalty for late renewal of Pharmacy licensePhotocopying of rules and regulations (per set)Photocopying of Public Law (Pharmacy Portion) (per set)Photocopying of other records (first 5 copies)Photocopying (each additional sheet) 100.00 60.00 10.00 50.00 30.00 40.00 40.00 50.00 30.00 40.00 50.00 30.00 40.00 40.00 10.00 5.00 3.00 0.50Present this form with payment to cashier at any Treasurer of Guam office, then return the processed form to GBEP Office.Off-island applicants, return this form with payment to GBEP at the above address.OFFICE USE ONLY:Payment ( ) CheckReceipt #:( ) Money Order ( ) CashDate Paid:Account #:DPH 324156346( ) Credit CardStaff’s Initials:

GUAM BOARD OF EXAMINERS FOR PHARMACYDepartment of Public Health & Social Services194 Hernan Cortez Ave., Terlaje Bldg. Ste 213A Hagatña, Guam, 96910-5052CASHIER’S COPYRECORD OF ing Address(Street or P.O. Box #)Signature(City)(State)(Zip Code)DateVERIFICATION OF LICENSURE: Please print the complete name used on original license and your Social Security number.NameSS#FEE: Fee paid is NON-REFUNDABLE. Make all checks or money orders payable to TREASURER OF GUAM.Please check your st’s Licensure Application fee (charged once)Pharmacist’s License Renewal feeTemporary License feePharmacy Permit feePharmacy Permit Renewal feePharmacy Intern Application feePharmacy Intern Renewal feePharmacy Technician License feePharmacy Technician License Renewal feePenalty for late renewal of Pharmacy InternMiscellaneous permit fee (Wholesalers, Drug Outlets, etc.)Miscellaneous Permit RenewalPenalty for late renewal of Pharmacist’s licensePenalty for late renewal of Pharmacy licensePhotocopying of rules and regulations (per set)Photocopying of Public Law (Pharmacy Portion) (per set)Photocopying of other records (first 5 copies)Photocopying (each additional sheet) 100.00 60.00 10.00 50.00 30.00 40.00 40.00 50.00 30.00 40.00 50.00 30.00 40.00 40.00 10.00 5.00 3.00 0.50Present this form with payment to cashier at any Treasurer of Guam office, then return the processed form to GBEP Office.Off-island applicants, return this form with payment to GBEP at the above address.OFFICE USE ONLY:Payment ( ) Check( ) Money Order ( ) Cash( ) Credit CardReceipt #: Date Paid: Staff’s Initials::Account #:DPH 324156346

LICENSE APPLICATION FOR PHARMACIST BY ENDORSEMENT A. GENERAL INFORMATION: 1. Type or print in ink. 2. All forms must be filled completely by the applicant. Application fee should be made payable to TREASURER OF GUAM and is NON-REFUNDABLE. 3. Return complete application form to the Guam Board of Examiners for Pharmacy at the above address.