Independent Pharmacy Ownership Residency Application
Please check the box(es) for the site(s) to which you are applying:
☐ Central Pharmacy – Durham, NC☐ Drugco Discount Pharmacy – Roanoke Rapids, NC
☐O’Neals Drug Store – Belhaven, NC
☐Skywalk Pharmacy – Madison, WI
☐ Sun Ray Drugs – Philadelphia, PA
1. Applicant’s name and contact information
Last Name, First Name: Click here to enter text.
Street Address: Click here to enter text.
City: Click here to enter text.
State: Click here to enter text.
Zip: Click here to enter text.
Phone: Click here to enter text.
Email: Click here to enter text.
2. Have you ever been arrested or convicted of any violations of the law that would preclude licensure?
☐ YES ☐ NO
If yes, please explain:
Click here to enter text.
3. List the contact information for the three persons from whom you have requested a letter of reference
Name / Email / PhoneClick here to enter text. / Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text. / Click here to enter text.
I hereby certify that the above information is complete and correct to the best of my knowledge. I grant the UNC Eshelman School of Pharmacy and Independent Pharmacy Ownership Residency site(s) permission to request additional information, if necessary, from previous schools and employers concerning my academic and professional liability. If selected for the residency, I agree to abide by the rules and regulations of the Independent Pharmacy site and the UNC Eshelman School of Pharmacy. Please include an electronic signature by double clicking on the signature line below.
Please send all application materials (CV, letter of intent, pharmacy transcripts and letters of recommendation) via email by January 1st to:
Stefanie Ferreri, PharmD
Director, Independent Pharmacy Ownership Residency Program
UNC Eshelman School of Pharmacy