Applications and Forms
Use the following links to access the appropriate applications to license, renew or make changes to existing permits, licenses or registrations.
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Pharmacy |
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Resident Pharmacy Application [PDF - 55KB] - Use this application for new resident pharmacy permits, or location, address, ownership and name changes for existing resident pharmacy permits.
Non-resident Pharmacy Application [PDF - 155KB] - Use this application for new non-resident pharmacy permits, or location, address, ownership and name changes for existing non-resident pharmacy permits.
Medicinal Gas Permit Application [PDF - 58KB] - Pharmacist Consultant not required for out-of-state facilities.
Use this application for new medicinal gas pharmacy permits, or location, address, ownership and name changes for existing medicinal gas pharmacy permits.
Clinical Practice Pharmacy Application [PDF - 57KB] - Use this application for new clinical practice pharmacy permits, or location, address, ownership and name changes for existing clinical practice pharmacy permits.
Resident Pharmacy Renewal Application [PDF - 37KB] - $100.00
Non-Resident Pharmacy Renewal Application - $100.00
Medicinal Gas Permit Renewal [PDF - 48KB] - $100.00
Clinical Practice Pharmacy Renewal Application [PDF - 56KB] - $100.00
PIC change form [PDF - 96KB] - $5.00
Telephone Inspection Form [PDF - 33KB]
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Wholesalers/Manufacturers |
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Wholesaler/Manufacturer Application [PDF - 57KB] - Use this application for new wholesale distributor licenses or new manufacturer permits, or location, address, ownership and name changes for existing licenses or permits.
Wholesaler/Manufacturer Renewal Application [PDF - 43KB] - $100.00 fee
Pseudoephedrine Log Waiver Request Form [PDF - 53KB]
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Pharmacists |
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Pharmacist Interns |
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Form I - Pharmacist Intern Application [PDF - 45KB] - Once you have completed this application, please print, date and sign then submit to the Board office along with a passport sized photo, letter of acceptance into a college of pharmacy [a copy of your FPGEC certificate for foreign graduates] and payment.
Form II - Pharmacist Preceptor Affidavit [PDF - 46KB]
Form III - Pharmacist Internship Report [PDF - 30KB]
Form IV - Academic Experience Affidavit
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Pharmacy Technicians |
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Home Medical Equipment License |
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Continuing Education Approval Form |
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