Test Center

Preference
Enter 3-digit code
1st
2nd
Acknowledgement
I agree to adhere to all policies and procedures outlined in the current PCAT Candidate Information Booklet and on
the PCAT website and attest that the information provided by me on this form is true to the best of my knowledge.
I further certify that my own name and signature appear below on this form.
Signature Todays Date: Month/ Day/ Year
An application without a signature will not be processed.
Note. The total fee for submitting a paper Registra-
tion Form is listed on the PCAT Website and in the
CIB (the Registration Fee + the Paper Registration
Form Fee). Be sure to submit this form and your fee
payment so that they are received by Harcourt As-
sessment, Inc. by the Special Registration Deadline
appropriate for the PCAT test date.
Please provide all the information requested below by printing clearly or checking the appropriate boxes. Harcourt
must receive this form by the Special Registration Deadline. No late paper Registration Forms will be accepted.
Copyright 2007 by Harcourt Assessment, Inc. All rights reserved.
Last Name First Name MI
Social Security/ Social Insurance Number Birth Date: Month/ Day/ Year
Your Address: Street Number and Name
Apartment Number (or other address)
City State/Province ZIP/Postal Code Country
Daytime Telephone Number
Email Address
Test Date
Preference
Please refer to the PCAT
website for upcoming
test dates
Examination History
Have you taken the PCAT before?
(check one) Yes No
If you have taken the PCAT before, indicate the most recent test date:
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Registration Form
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Doha- Qatar
Optional Information
By providing this information, you are consenting to its use for research and planning purposes only in
Harcourt Assessments ongoing efforts to improve the PCAT.
Institutions or Organizations to Receive an Official Transcript
Code Numbers for 3 Reports Included in Test Fee: Code Numbers for Additional Reports at an additional fee:
If an institution or organization to which you would like to send an Official Transcript does not have a designated cod e,
email PSE Customer Relations at scoring.services@harcourt.com or call 1-800-622-3231.
Need for Special Arrangements
If you need any special testing arrangementssuch as a Special Testing
Location, a Non-Saturday Test Administration, or a foreign test site
or if you need special accommodations because of a disability,
check here:
Along with this form, be sure to include any required fee and all supporting
documentation as described in the CIB and on the PCAT website.
Information Release
Schools of pharmacy may request your
name and address for recruitment purposes.
If you do not wish this information to be
released, check here:
PCAT Fees
Fee for Submitting a Paper Registration Form . . . . . See the PCAT Website
(Includes 3 Score Official Transcripts and 1 personal Score Report)
Additional Official Transcript Fee . . . . . . . . . . . . . . . . . . ______
Number of reports x Fee (See the PCAT Website)
Special Testing Location Fee . . . . . . . . . . . . . . . . . . . . . ______
(See the PCAT website)
Total Fee Payment Included . . . . . . . . . . . . . . . . . . . . . . ______
Payment
A money order for the Total Fee Payment
on the left must accompany this Registration
Form and must be made out to Harcourt
Assessment, Inc. Mail this form and your
payment to one of the addresses listed on
the PCAT website or on the inside front
cover of the current PCAT Candidate
Information Booklet.
Sex
(check one)
Male
Female
Linguistic
Background
(check one)
English
Spanish
Other
Ethnic Identification
(check one)
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or
Other Pacific Islander
White
Other
Completed College Courses
Biology
Chemistry
None
Less
Than
One
Year
One
Year
More
Than
One
Year
Current Educational Status (check one)
High School Student
High School Graduate
CollegeFirst Year
CollegeSecond Year
CollegeThird Year
CollegeFourth Year
College Graduate
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Copyright 2007 by Harcourt Assessment, Inc. All rights reserved.
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