SWOSU RxPath Registration Form

SWOSU RxPath Registration Form
Student Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student E-mail*
example@example.com
Mobile Number*
Format: (000) 000-0000.
High school attended:*
High school city & state:*
Expected graduation date:*
Current overall high school GPA:*
Highest ACT composite score:
Leave blank if you have not taken the ACT exam.
Highest SAT combined score:
Leave blank if you have not taken the SAT exam.
Name(s) of parent(s) or legal guardian(s)*
YesNo
If "yes", please list the event attended:
YesNo
If "yes", please list the name and location of the pharmacy in which you worked/shadowed as well as the approximate number of hours:
Please describe below why you are interested in becoming a pharmacist:
Should be Empty: