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					                          UNIVERSITY OF KENTUCKY COLLEGE OF PHARMACY
                       COMMUNITY PHARMACY RESIDENCY APPLICATION
                            INSTRUCTIONS FOR COMPLETING
                                PROGRAM APPLICATIONS



GENERAL INSTRUCTIONS FOR APPLICATION: Please complete the following application
template. Although some of the information may be contained in a CV, it is important to fully answer each
question. This application has been provided to you in an electronic format for ease of completion. To navigate
between individual fields, use the <tab> and <shift + tab> keys. Submit one hardcopy of the application and
one electronic copy via email to Dr. Divine in a Word or PDF file.


CURRICULUM VITAE: Enclose a hardcopy of your current CV and electronic copy via email. It
should include (but not be limited to) schools or universities attended (including dates), degrees conferred or
expected, honors and awards, certifications, rotation/advanced practice experiences, extracurricular/community
service activities, presentations, publications, research projects, and other pertinent information.


PERSONAL (COVER) LETTER: This letter of interest, addressed to Dr. Holly Divine should include
professional goals, both short-term and long-term, motivations for pursuing residency training, and why you are
interested in the University of Kentucky Community Residency program. Include this as a hardcopy and an
electronic copy via email.


TRANSCRIPT: Submit an official transcript of all courses completed during pharmacy school. The
transcript should come from your college or university.


PHOTOGRAPH: It is optional for you to provide a photograph with the application. The photograph will
assist us in recalling you and your interview when all candidates are considered.


RECOMMENDATIONS: Three letters of recommendation are required, one from a pharmacy employer,
one from an advanced practice experience preceptor, and one from a pharmacy faculty member. Please provide
each individual writing a recommendation with a copy of the enclosed Residency Applicant Recommendation
Request Form. They are to send their letter of recommendation directly to Dr. Divine. These letters must be
received no later than January 11, 2010.


DEADLINE: All application materials must be received no later than January 11, 2010.


INTERVIEW: An on-site interview at the University of Kentucky is required if your application is accepted.
  NAME:
                    Last                          First                  Middle



  SOCIAL SECURITY NUMBER (REQUIRED FOR UNIVERSITY NMS MATCH NUMBER (REQUIRED
  EMPLOYMENT):               ________________ FOR MATCH):

  [   ]* PERMANENT ADDRESS:

       Street
                                              -
       City                 State            Zip
      ( ) -
       Telephone


  [   ]* PRESENT ADDRESS:                                              Attach Photo
                                                                        (optional)
       Street
                                              -
       City                 State            Zip
      ( )       -                       ( ) -
       Telephone (home)                      (work)
      @
       E-mail Address



      *Please indicate your preferred mailing address
  during the recruitment process.


  PLEASE INDICATE WHICH COMMUNITY RESIDENCY PROGRAM YOU ARE
  INTERESTED IN:
                     AMERICAN PHARMACY SERVICES CORPORATION
                     KROGER


SUBMISSION: Full application packet must be received by January 11, 2010. Address all
materials to:
                         Holly S. Divine, PharmD, CGP, CDE
                         Department of Pharmacy Practice and Science
                         University of Kentucky College of Pharmacy
                         725 Rose Street
                         Lexington, KY 40536-0082
                         holly.divine@uky.edu
WORK EXPERIENCE:

Describe previous pharmacy work experience. Include name of employer, dates of
employment, job title, and your specific responsibilities and experiences (e.g., managerial
responsibilities, patient care activities, compounding, dispensing, computerization, etc).
LICENSURE:

Pharmacy residents are expected to become licensed interns in the Commonwealth of Kentucky
prior to the beginning of their residency. Residents are also expected to complete the licensure
process for Kentucky or begin the reciprocation process by the end of July. To be eligible to
reciprocate licensure from another state, you must have been licensed for a minimum of one
year in good standing.

Contact the Kentucky Board of Pharmacy to determine your eligibility for licensure in July. It
is your responsibility to determine your eligibility for licensure.

KENTUCKY BOARD OF PHARMACY
Spindletop Administration Bldg., Ste 302
2624 Research Park Dr.
Lexington, KY 40511
Phone: [859] 246-2820
Fax: [859] 246-2823
pharmacy.board@ky.gov
www.pharmacy.ky.gov
CLINICAL PRACTICE EXPERIENCE:

List advanced pharmacy practice experience rotations taken and those scheduled. Include
specific activities and responsibilities for those rotations already taken. If you are a registered
pharmacist practicing in a clinical setting, describe your practice site and your responsibilities.
ESSAY QUESTIONS:

1.   Describe a specific situation during the past year where you enhanced the provision of
     pharmaceutical care.




2.   Describe a situation from the past that involved conflict among your peers and how you
     worked to resolve the issue.



RECOMMENDATIONS:

List the name, address, phone number, fax number, and e-mail address of those individuals
whom you have asked to write a letter of recommendation on your behalf.

1. Pharmacy Employer




2. Advanced Pharmacy Practice Experience (APPE) Preceptor




3. Pharmacy Faculty Member




Applicant Signature                   Date
                            UNIVERSITY OF KENTUCKY COLLEGE OF PHARMACY
                         COMMUNITY PHARMACY RESIDENCY APPLICATION

                                     RECOMMENDATION REQUEST
To be completed by the applicant
Name of Applicant:                             First Name                   MI           Last Name
(Please print or type)
                                               Street Address or P.O. Box
                                                                                           -
                                               City                     State                  Zip
                                                ( )    -
                                               Telephone


I waive the right to review this recommendation.
                                                                     Signature of Residency Applicant


To be completed by recommender
Applicants to our residency program are required to have letters of recommendation submitted by persons
who are in a position to evaluate their qualifications for residency training. The recommender is asked to
make an honest appraisal of the applicant's character, personality, abilities, and suitability for a pharmacy
residency. All comments and information provided will be kept in strict confidence.

In your letter of recommendation, please address each of the following:
• How long you have known the applicant and in what capacity?
• What are the applicant's strengths and weaknesses?
• How would you rate the applicant's time management skills?
• How is the applicant able to deal with difficult personalities and situations?
• How is the applicant motivated to perform at a high level in stressful situations?
• What is your recommendation on the applicant’s candidacy?

                                                            Completed request form and letter must
   Signature of Recommender                                 be received no later than January 11, 2010. The
                                                            letter of recommendation may be initially
   Typed or printed name and title                          sent by e-mail or fax, with a hard copy
                                                            to immediately follow. Send materials to:
   Institution/Company                                           Holly S. Divine, PharmD, CGP, CDE
                                                                 Department of Pharmacy Practice and Science
   Street Address or P.O.Box                                     University of Kentucky College of Pharmacy
                                    -                            725 Rose Street
   City                  State    Zip                            Lexington, KY 40536-0082
   ___________________________________________                   Fax (859) 257-3424
   E-mail Address                                                holly.divine@uky.edu
   (    )  -             (    ) -
   Telephone             Fax
                            UNIVERSITY OF KENTUCKY COLLEGE OF PHARMACY
                         COMMUNITY PHARMACY RESIDENCY APPLICATION

                                     RECOMMENDATION REQUEST
To be completed by the applicant
Name of Applicant:                             First Name                   MI           Last Name
(Please print or type)
                                               Street Address or P.O. Box
                                                                                           -
                                               City                     State                  Zip
                                                ( ) -
                                               Telephone


I waive the right to review this recommendation.
                                                                     Signature of Residency Applicant


To be completed by recommender
Applicants to our residency program are required to have letters of recommendation submitted by persons
who are in a position to evaluate their qualifications for residency training. The recommender is asked to
make an honest appraisal of the applicant's character, personality, abilities, and suitability for a pharmacy
residency. All comments and information provided will be kept in strict confidence.

In your letter of recommendation, please address each of the following:
• How long you have known the applicant and in what capacity?
• What are the applicant's strengths and weaknesses?
• How would you rate the applicant's time management skills?
• How is the applicant able to deal with difficult personalities and situations?
• How is the applicant motivated to perform at a high level in stressful situations?
• What is your recommendation on the applicant’s candidacy?

                                                            Completed request form and letter must
   Signature of Recommender                                 be received no later than January 11, 2010. The
                                                            letter of recommendation may be initially
   Typed or printed name and title                          sent by e-mail or fax, with a hard copy
                                                            to immediately follow. Send materials to:
   Institution/Company                                           Holly S. Divine, PharmD, CGP, CDE
                                                                 Department of Pharmacy Practice and Science
   Street Address or P.O.Box                                     University of Kentucky College of Pharmacy
                                    -                            725 Rose Street
   City                  State    Zip                            Lexington, KY 40536-0082
   ___________________________________________                   Fax (859) 257-3424
   E-mail Address                                                holly.divine@uky.edu
   (    )  -             (    ) -
   Telephone             Fax
                            UNIVERSITY OF KENTUCKY COLLEGE OF PHARMACY
                         COMMUNITY PHARMACY RESIDENCY APPLICATION

                                     RECOMMENDATION REQUEST
To be completed by the applicant
Name of Applicant:                             First Name                   MI           Last Name
(Please print or type)
                                               Street Address or P.O. Box
                                                                                           -
                                               City                     State                  Zip
                                                ( ) -
                                               Telephone


I waive the right to review this recommendation.
                                                                     Signature of Residency Applicant


To be completed by recommender
Applicants to our residency program are required to have letters of recommendation submitted by persons
who are in a position to evaluate their qualifications for residency training. The recommender is asked to
make an honest appraisal of the applicant's character, personality, abilities, and suitability for a pharmacy
residency. All comments and information provided will be kept in strict confidence.

In your letter of recommendation, please address each of the following:
• How long you have known the applicant and in what capacity?
• What are the applicant's strengths and weaknesses?
• How would you rate the applicant's time management skills?
• How is the applicant able to deal with difficult personalities and situations?
• How is the applicant motivated to perform at a high level in stressful situations?
• What is your recommendation on the applicant’s candidacy?

                                                            Completed request form and letter must
   Signature of Recommender                                 be received no later than January 11, 2010. The
                                                            letter of recommendation may be initially
   Typed or printed name and title                          sent by e-mail or fax, with a hard copy
                                                            to immediately follow. Send materials to:
   Institution/Company                                           Holly S. Divine, PharmD, CGP, CDE
                                                                 Department of Pharmacy Practice and Science
   Street Address or P.O.Box                                     University of Kentucky College of Pharmacy
                                    -                            725 Rose Street
   City                  State    Zip                            Lexington, KY 40536-0082
   ___________________________________________                   Fax (859) 257-3424
   E-mail Address                                                holly.divine@uky.edu
   ( )     -            (     ) -
   Telephone             Fax

				
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