Pharmacy Technician Course Enrollment Application
Please fill out the following form to be considered for the Tech Road Rx Academy Online Pharmacy Technician Program
Name
*
First Name
Last Name
Email
*
example@example.com
Are you at least 17 year old?
*
Please Select
yes
no
Phone Number
*
Please enter a valid phone number.
Do you live in Maryland or plan to work there after you become a CPhT?
*
Please Select
yes
no
Do you have access to a working device (PC, laptop etc) with reliable Wifi/internet?
*
Please Select
yes
no
Which of the following applies to you?
*
Please Select
I have a High School Diploma
I have a GED
How did you hear about our program?
*
Maryland Website
PTCB website
Word of Mouth
Social Media
Other
Submit
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