Professional Credential Services, Inc. Pop BOX 198788- Nashville, TN 37219-8689 Preceptor’s Affidavit of Internship Hours This form is to be submitted each time an intern completes training at a new location. This form must be filed for each intern supervised by the preceptor. A Name of Intern: First Last (Must be Included) Intern’s E-mail address: Preceptor’s Name State License No. License Expiration Date *Intern Erg. # Name of Pharmacy in which you practice on a full-time basis Pharmacy Location: street Address City State Are you the owner of the pharmacy? B. Reported Intern Hours.

Provide total hours of internship training under the preceptor’s direct supervision for the specified work period. ‘Off hours accrued. Zip Telephone Number Intern’s working period should be reported in 3-6 month increments if the internship is at least 12 months in length. Intern Dates of Employment: To: MM/DADDY Preceptor’s Initials Number of Intern Hours completed during the work period stated above: (Example: two hundred and forty) From: MM/AD/ In regards to the intern’s quality of work, has the intern met your expectation level for impoliteness and neatness of work accomplished?

YES NO c. Evaluation of Intern. Answer each question listed. This form MUST be mailed to PC’s within 15 business days. In regards to the intern’s quantity of work, has the intern met your expectation level for duties performed and time frame in which duties were accomplished? YES NO In regards to the intern’s level of professional knowledge, has the intern met your expectation level for applying their professional knowledge and skill level? YES NO Overall appraisal: Has the intern met your expectation level for overall Job reference? YES NO D.

Date of interview with intern: Intern’s affidavit: By my signature below, I attest that I have read and discussed this appraisal. Affix Notary Signature of Intern (in the presence of a Notary Public) Is your pharmacist Registration(s)/License(s) currently in good standing with the Board(s)? Preceptor’s affidavit: I hereby certify under penalties of perjury that the above information is true and correct. Signature of Preceptor (in the presence of a Notary) Date Signature of Notary Public Print name of Notary Public My commission expires on MM/DADDY

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