By Franklin R. Cole, Ph.D. - College of Pharmacy - Idaho State ...
By Franklin R. Cole, Ph.D. - College of Pharmacy - Idaho State ...
By Franklin R. Cole, Ph.D. - College of Pharmacy - Idaho State ...
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<strong>Idaho</strong> <strong>State</strong> University<br />
<strong>College</strong> <strong>of</strong> <strong>Ph</strong>armacy<br />
Externship Certification Form<br />
These hours may be certified only by an individual currently licensed as a preceptor<br />
in the state in which the externship is completed.<br />
This is to certify that ____________________________________________ has<br />
(first and last name <strong>of</strong> student)<br />
completed ________________ clock hours in direct pharmaceutical care<br />
(number <strong>of</strong> hours)<br />
at _________________________________________ in _________________________.<br />
(name <strong>of</strong> pharmacy)<br />
(city, state)<br />
Name <strong>of</strong> Preceptor:<br />
<strong>Ph</strong>one Number:<br />
Site License Number:<br />
Licensing <strong>State</strong>:<br />
<strong>Ph</strong>armacy License Number:<br />
______________________________________<br />
(Preceptor’s signature)<br />
___________________________<br />
(Date)<br />
2006 <strong>College</strong> <strong>of</strong> <strong>Ph</strong>armacy Student Handbook 40