Pharmacy School Evaluation Waiver Form
Use this form to submit pharmacy school evaluation waiver details, applicant information, and the required waiver acknowledgment for review.
Applicant and Program Information
Applicant Full Name
*
First Name
Middle Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Pharmacy School Name
*
Program Level / Year in Program
*
Please Select
P1
P2
P3
P4
Graduate/Residency Year
Other
Evaluation Site / Rotation Name
*
Evaluation Waiver and Submission Acknowledgment
I acknowledge and accept the waiver terms
*
I agree
Evaluation Details
Evaluation Purpose / Type
*
Please Select
Academic Reference
Professional Reference
Character Reference
Supervisor Assessment
Committee Review
Other
Evaluator / Contact Name
*
First Name
Middle Name
Last Name
Submit Form
Should be Empty: