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Test CenterPreferenceEnter 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 Today’s 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 r eceive 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 DatePreference

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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Optional Information

By providing this information, you are consenting to its use for research and planning purposes only in

Harcourt Assessment’s 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 ArrangementsIf you need any special testing arrangements—such 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 f orm, be sure to include any required fee and all supporting

documentation as described in the CIB and on the PCAT website.

Information ReleaseSchools of pharmacy may request your

name and address for recruitment purposes.

If you do not wish this information to be

released, check here:

PCAT FeesFee 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

LinguisticBackground(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

LessThanOne Year

One Year 

MoreThanOne Year 

Current Educational Status (check one)

High School Student

High School Graduate

College—First Year

College—Second Year 

College—Third Year

College—Fourth Year

College Graduate

Page 2Copyright © 2007 by Harcourt Assessment, Inc. All rights reserved.

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