PTCB Recognized Education Program Attestation
This attestation is to be completed and submitted by a program director.
 
 
 
Program Information
 
 
 
Name of Organization/Educational Institution*
 
 
Program Name*
 
 
Campus Name/Location
 
 
Address Street 1*
 
 
Address Street 2
 
 
City*
 
 
State (Please do not abbreviate)*
 
 
Zipcode*
 
 
Country
 
 
Phone Number*
 
 
Fax Number
 
 
Website
 
 
 
 
 
Program Type*
 
 
 
 
If other, please describe
 
 
 
 
 
 
 
Please select one of the following that best describes your program
 
 
 
 
 
 
How is your program delivered to pharmacy technician students?*
 
 
 
 
If other, please describe
 
 
 
 
 
 
 
What is the approximate total cost to attend your pharmacy technician education/training program?*
 
 
 
 
 
 
How many new students did you enroll in the previous calendar year? *
 
 
 
 
 
What is the maximum capacity of new students your program can enroll in a calendar year?*
 
 
 
 
 
What is your program completion rate?
 
 
 
(Example: Enter "0.75" if your graduation rate is 75%)
 
 
 
Does your program require students to take the PTCE?*
 
 
 
 
 
Is your program offered in more than one state?
 
Yes
No
 
 
 
 
 
Program Director Information
 
 
 
Prefix
 
 
 
 
First Name*
 
 
Last Name*
 
 
 
Email*
 
 
Phone Number*
 
 
 
 
 
 
Attestation
 
 

By submitting this recognition form, I do hereby certify that the required knowledge areas (2020 PTCB CPhT Knowledge Reference), are included in the curriculum of the above named program and that the information on this form is true and correct to the best of my knowledge. I understand that PTCB may request to review the program curriculum, or use other appropriate means, in order to verify the accuracy of the information on this form and I agree to fully cooperate with any such requests. I understand that material misrepresentations in this form may affect the certification eligibility of those who complete the program, and that PTCB may refer misrepresentations on this form to state regulatory bodies for review. 
 
 
 
Full Name*
 
 
 
Today's Date
 
 
 
 
 
 
 
 
I have read and accept the PTCB Recognition Program Terms and Conditions*
 
Yes
 
 
 
 
 
 
 
I have read and accept the PTCB Pass Rate Data License Agreement*
 
Yes