657—5.7(155A) Registration application form.
	5.7(1) Required information. The application form for a pharmacy support person registration shall require the following:
	a. 	Information sufficient to identify the applicant including, but not limited to, name, address, date of birth, gender, and social security number;
	b. 	Work experience;
	c. 	Current place or places of employment;
	d. 	Any other information deemed necessary by the board.
	5.7(2) Declaration of current impairment or limitations. The applicant shall declare any current use of drugs, alcohol, or other chemical substances that in any way impairs or limits the applicant’s ability to perform the duties of a pharmacy support person with reasonable skill and safety.
	5.7(3) History of felony or misdemeanor crimes. The applicant shall declare any history of being charged, convicted, found guilty of, or entering a plea of guilty or no contest to a felony or misdemeanor crime (other than minor traffic violations with fines under $100).
	5.7(4) History of disciplinary actions. The applicant shall declare any history of disciplinary actions or practice restrictions imposed by a state health care professional, licensure, or registration authority.
	5.7(5) Sworn signature. The applicant shall sign the application under penalty of perjury and shall submit the application to the board with the appropriate nonrefundable fees pursuant to rule 657—5.9(155A).
[ARC 8673B, IAB 4/7/10, effective 6/1/10; ARC 5543C, IAB 4/7/21, effective 5/12/21]