Application for NDSU Pharmacy Student Intern Licensure

Applicant Information

You must keep the Board notified of any changes to your information.

Contact Information


During rotations, do you have an alternative address besides the one above?	Yes	No

Pre-Pharmacy Intern


Intern License # Only if applicable.One will be assigned if you don’t have one.

Professional PharmD Year


Select Academic Status Not counting pre‑pharmacy years; only the PharmD program.
Is your education track considered non‑traditional?	Yes	No


Please provide an explanation of your non‑traditional educational background.
Have you had any violations or convictions for unlawful acts?	Yes No