657—3.8 (155A) Application form.
	 3.8(1) Required information. The application for a certified pharmacy technician registration, pharmacy technician trainee registration, or uncertified pharmacy technician registration shall include 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.   	 Educational background;
	  c.   	 Work experience;
	  d.   	 Current place or places of employment;
	  e.   	 Any other information deemed necessary by the board and as provided by this rule.
	 3.8(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 technician with reasonable skill and safety.
	 3.8(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).
	 3.8(4) History of disciplinary actions. The applicant shall declare any history of disciplinary actions or practice restrictions imposed by a state health care professional or technician licensure or registration authority.
	 3.8(5) Additional information. The following additional information shall be required from an applicant for the specified registration.
	  a.   	 Technician trainee. The applicant for technician trainee registration shall identify the source of technician training, the anticipated date of completion of training, and the anticipated date of national certification.
	  b.   	 Certified pharmacy technician. The applicant for certified technician registration shall provide proof of current pharmacy technician certification. The applicant shall also identify all current pharmacy employers including pharmacy name, license number, address, and average hours worked per week.
	  c.   	 Licensed health care provider. In addition to the additional information required by paragraph “a,” “b” or “d” as applicable, a licensed health care provider shall provide evidence that the licensee’s professional license or registration is current and in good standing and is not subject to current disciplinary sanctions or practice restrictions imposed by the licensee’s professional licensing authority.
	  d.   	 Uncertified pharmacy technician. The applicant for uncertified pharmacy technician registration shall submit with the application for registration renewal one or more affidavits signed by the pharmacists in charge of one or more Iowa pharmacies where the applicant practiced as a pharmacy technician during the 18 months prior to submission of the application for registration. Affidavits shall be on a form provided by the board office.
	 3.8(6) Sworn signature. The applicant shall sign the application under penalty of perjury and shall submit the application to the board with the appropriate fees pursuant to rule 657—3.10(155A).
[ARC 9009B, IAB 8/11/10, effective 7/23/10]