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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

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