Pharmacy Experience Affidavit Please fill in all blank spaces. State of County or City of I, the undersigned, hereby certify that I am a licensed Pharmacist in the State of , Certificate No. ; and that received practical pharmacy experience as follows: Hours of Experience From To # of Weeks Hours per Week Hours Earned TOTAL HOURS reported on the form: I, (Supervising Pharmacist), do solemnly swear or affirm, under the penalties of perjury, that I have personally completed this form to the best of my knowledge and belief, that I understand that perjury on this form will constitute grounds for revoking any license issued which uses this form as a supporting document. Signature Pharmacy Address IMPORTANT NOTICE: This affidavit must be notarized and submitted with the APPLICATION FOR EXAMINATION AS A PHARMACIST or the APPLICATION FOR REINSTATEMENT EXAMINATION. Return to the Pharmacist Examination page Return to the Pharmacist Licensure main page