Please Print or Type

1.  Name: _______________________________________________________________________________________________________

                        (Last)                                               (First)                                        (Middle)

2.  College of Pharmacy:  __________________________________________________  Phone: (____)_________________

3.  Student Mailing Address: ______________________________________________________________________________

__________________________________________________________________________ Phone: (____)_________________

4.  Home Address (if different than above): ___________________________________________________________________

__________________________________________________________________________Phone: (____)__________________

E-mail address ___________________________________________________

5.  Date of Birth: _____________________________             Place of Birth: _______________________________________

                                                                                                                                  (City/State/Country)

6.    Male            Female

       Single          Married                                          Social Security Number: ______________________________

7. Education                                                Dates attended                           Degree/Diploma/# credits

High School/Location ______________________________________________________________________________________

College (Pre-Pharmacy)/Location ____________________________________________________________________________

Date you expect to receive your degree in Pharmacy (Mo./Yr.) ___________________________

8.  Previous Pharmacy-related experience:

                               Name of Employer                                                      Dates Employed         Position

(1) _____________________________________________________________________________________________________

(2) _____________________________________________________________________________________________________

(3) _____________________________________________________________________________________________________

9. Previous Other Employment:

Name of Employer Date Employed Position

(1) _____________________________________________________________________________________________________

(2) _____________________________________________________________________________________________________

(3)______________________________________________________________________________________________________

10. What are your pharmacy career goals?

________________________________________________________________________________________________________

________________________________________________________________________________________________________

11. What do you expect to receive by participating in the internship program?

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

12. References: (At least one reference should be a former employer)

Name: ________________________________________ Title: ________________________ Phone:____________________

Address: ________________________________________________________________________________________________

Name: ________________________________________ Title: ________________________ Phone:____________________

Address: ________________________________________________________________________________________________

Name: ________________________________________ Title: ________________________ Phone:____________________

Address: ________________________________________________________________________________________________

13. The final step in the selection process in an interview with the manager of the site for which you have been selected. Reasonable transportation expenses will be paid if you must travel to a city other than the one in which you are attending the College of Pharmacy.

If selected, your schedule will be determined by the Site Manager. You may be required to work all shifts.  You must provide your own transportation to and from work. (Public transportation may not be available the hours you are required to work.)
The hours worked during these programs are not recognized by the Texas State Board of Pharmacy toward the hours needed for licensure.  You will be required to meet all pre-employment requirements for the company where you will be serving your program (including a physical and drug screening).

__________________________________________________________________

Signature of Applicant                                                                    Date

Mail Applications to:
TSHP R & E Foundation Internship Programs
3000 Joe DiMaggio #30-A, Round Rock, TX 78665-3994
Applications must be received by February 8, 2008