Application for Pharmacy Practice Residency Program

PGY1 Pharmacy Residency Application (Supplement to PhORCAS online materials)

Home of the Medical College of Georgia—residency offered in conjunction with the College of Pharmacy

Deadline for receipt of application is January 1st. Early application is encouraged

Name: ______(last) (first) (middle)

[ ] Check if you currently have a pharmacy license? If yes, give state and number: ______

If no, when are you eligible to take the Georgia board*? _____ Current GPA:____ (as of ___ _) *requires GA Pharmacist Practical Exam, see gbp.georgia.gov/events

Do you have pharmacy intern (work) experience outside of Pharm.D. program IPPE/APPE? [ ] No [ ] Yes (~ total hours: ____ ) Comments:

In addition to the application in PhORCAS, applicants to the residency are asked to complete and upload this application form, including the essay on page 2, and to have at least three (3) references provide a recommendation and feedback on your abilities/performance using the standard reference template in PhORCAS. Please provide our “Recommendation Request” information form to each individual who you are asking to provide a PhORCAS reference in support of your application.

We require a detailed reference (in PhORCAS) from at least three individuals who can provide input into your readiness for success in the residency.

Names and contact information for individuals who will be providing PhORCAS recommendation

______Name (Relationship to Applicant) Email address Telephone Number

(optional) ______Name (Relationship to Applicant) Email address Telephone Number

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Describe at least three personal goals you have for your PGY1 year and how our residency program in particular can help you meet your goals.

[ ] By checking this box, I waive the right to review any letters of recommendation submitted on my behalf. Typing your name below will serve as your electronic signature

Signature: ______Date: ______

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