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Recertification Online Application
First name*	Initial	Last name*	Suffix
Address*	City*	State	Zip*
Home phone*	Work phone	Fax	Email*
Date of Birth	Previous Name
Check if address is less than 2 years
Certficate number*	Original Certificate Issue Date	Original Certificate Issue State*

ExCPT Online Recertification Application

THE FOLLOWING QUESTIONS MUST BE ANSWERED FAILURE TO DO SO WILL RESULT IN REJECTION OF THIS APPLICATION

Within the last four years have you been charged in any felony or have you been adjudicated guilty or entered a plea of guilty or nolo contrendre in any felony? No Yes

Has your pharmacy technician registration, licensure or certification been subject to disciplinary action by a board of pharmacy in any state during the last four years? No Yes

Have you participated in at least 20 hours of continuing education during the recertification period and will you be able to supply copies of certificates of participation upon request?
No Yes

I hereby attest that the foregoing statements, as well as any other statements submitted as a part of this ExCPT recertification process are true and correct to the best of my knowledge and that I have fulfilled the necessary continuing education requirements for renewing my certification.