Forms

Established 1903

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Forms & Applications

Guidelines / Instructions
	Applying for Intern License (PDF)
	Applying for Nonprescription Drug Retailer Permit
	Applying for Nonprescription Drug Retailer Permit (in Spanish)
	Applying for Pharmacist License (NAPLEX exam & score transfer instructions) (PDF)
	Applying for Pharmacist License (reciprocity instructions) (PDF)
	Applying for Pharmacy Permit
	Applying for Technician License (PDF)
	Applying for Wholesaler Permit (PDF) ◄ UNDER REVISION


Applications
	Compressed Medical Gas Distributor Application (PDF)
	Compressed Medical Gas Supplier Application (PDF)
	Durable Medical Equipment (DME) Application (PDF)
	Immunization Application (PDF)
	Intern Application (PDF)
	Intern Preceptor Application (PDF)
	Manufacturer Permit Application (PDF)
	Nonprescription Drug Retailer Permit Application (PDF)
	Permit Location/Remodel Application (PDF)
	Pharmacist License Application (exam) (PDF)
	Pharmacist License Application (reciprocity) (PDF)
	Pharmacy Permit Application (PDF)
	Renewal - License Application (for individuals) (PDF)
	Renewal - Permit Application (for facilities) (PDF)
	Technician License Application (PDF)
	Wholesaler Permit Application (PDF)


Other Forms
	Address / Employment change form (PDF)
	Certificate Request / Replacement (PDF)
	Character Voucher (PDF)
	Consumer Complaint form (PDF)
	Controlled Substances Inventory Book (PDF)
	DEA form 41 (Registrants Inventory of Drugs Surrendered) (PDF)
	DEA form 106 (Theft or Loss of Controlled Substances)
	DEA form 224 (Registration Application)
	Documentation of Eligibility form for Licensure or Renewal (PDF)
	Fraud Alert form (formerly Fax Net) ◄ NEW
	Intern Hours Report form (PDF)
	License / Permit fee chart (PDF)
	Management Agreement for Pharmacy change of ownership (PDF)
	Requests for Mailing Lists of Licensees/Permitees (PDF)
	Termination of Employment (PDF)
	W-9 form (PDF)
	Wholesale Surety Bond form (PDF)

License / Permit Verification

License / Permit Online Applications
(please note: some versions of Internet Explorer may not be fully compatible - an alternate browser is recommended)

Online renewals ended on Sunday, November 3rd, 2013.

If you need to renew your license or permit you MUST renew by mail (check/money order) or in person (check/money order/exact change).

DO NOT apply for new license or permit; this will DELAY your renewal process.

2013 Renewal Fee Chart

License Renewal Form
(for individuals) (PDF)

Permit Renewal Form
(for facilites) (PDF)