Form 4 - Certification of an Internship in Pharmacy

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This form is not required for PharmD graduates from ACPE or CCAPP accredited programs.

Use Form 4 to certify the completion of the required internship, which can only be performed under an authorized permit. A separate Form 4 is required for each pharmacy, and for each preceptor and should be completed, signed by both intern and preceptor, and returned to the Department at the address at the end of the form. Pharmacy payroll records may be requested during periodic routine audits.

Department must receive Form 4 and approve the internship certification before you will be admitted to the MPJE. Incomplete forms or failure to comply with the internship requirement will prevent your admission to the exam.

• Section I: Please complete this section of the form before submitting it to your preceptor pharmacist.
• Section II: Your preceptor pharmacist must complete this section.
• Section III: You and your preceptor pharmacist must sign in this section, affirming that the statements in Section I and Section II are true.
• Section IV: If you are seeking credit for an internship completed in another state, submit this form to the authorized representative of that State's Board of Pharmacy for verification.

Electronic Verification of Experience

The Office of the Professions (OP) will accept experience forms directly from supervisors provided that:

• OP can independently verify that the documentation is received directly from the supervisor
• The applicant had no opportunity to directly alter the experience form before it is sent or transmitted.
• Any experience documentation submissions should be made electronically to DPLSExperience@nysed.gov*.

*Do NOT use this email to submit a question, as we will be unable to provide a response. Submit a Contact Us Form for questions regarding specific applications or to check the status of a licensure application.