PMP Registration Info Change Form- Pharmacy Technicians & Pharmacy Technicians in Training

Drivers License Number

Pharmacy DEA Number

First Name

Last Name

Incorrect Email Address (If you do not know then please leave blank)

Correct Email Address

License Number (Please make sure to add any leading letters and zeros)

Last 4 Digits of SSN

Primary Phone Number

Date of Birth

Email Address Of Pharmacist(s) You Will Be Delegating For (Please verify with your pharmacist(s) which email address they use for their PMP account)

Multiple email addresses may be separated by commas. Emails are only sent to cc and bcc addresses if a To email address is provided.

Employment

Employer

Employer Phone Number

Please indicate your primary employer address (only one address can be added to your account). If you are retired or unemployed, please indicate your mailing address.

Employer Address

Address 2

Employer City/Town

Employer State/Province

Employer ZIP/Postal Code

Employer Country