Third Party Logistics Provider (3PL) Forms
Permit Specific
3PL - Renewal
3PL Permit Specific
Last Revision - 08.24.2021
Miscellaneous
Relocation - Resident
Pharmacy Permit Misc
Remote Permit Misc
Wholesalers Permit Misc
Manufacturer Permit Misc
Medical Gas/DME Permit Misc
3PL Permit Misc
Last Revision - 04.27.2021
DEA - form 106 (Theft or Loss of Controlled Substances)
Pharmacy Permit Misc
Remote Permit Misc
Wholesalers Permit Misc
Manufacturer Permit Misc
Medical Gas/DME Permit Misc
3PL Permit Misc
Last Revision - web link
DEA - form 224 (Registration Application)
Pharmacy Permit Misc
Remote Permit Misc
Wholesalers Permit Misc
Manufacturer Permit Misc
Medical Gas/DME Permit Misc
3PL Permit Misc
Last Revision - web link
DEA - form 41 (Registrants Inventory of Drugs Surrendered)
Pharmacy Permit Misc
Remote Permit Misc
Wholesalers Permit Misc
Manufacturer Permit Misc
Medical Gas/DME Permit Misc
3PL Permit Misc
Last Revision - 10.22.2015
Deviation Request
Pharmacy Permit Misc
Remote Permit Misc
Wholesalers Permit Misc
Manufacturer Permit Misc
Medical Gas/DME Permit Misc
3PL Permit Misc
Last Revision - 02.16.2019
Duplicate / Replacement Request
Technician License Misc
Intern License Misc
Pharmacist License Misc
Pharmacy Permit Misc
Remote Permit Misc
Wholesalers Permit Misc
Manufacturer Permit Misc
Medical Gas/DME Permit Misc
3PL Permit Misc
Last Revision - 10.15.2021
Name Change Request
Technician License Misc
Intern License Misc
Pharmacist License Misc
Pharmacy Permit Misc
Remote Permit Misc
Wholesalers Permit Misc
Manufacturer Permit Misc
Medical Gas/DME Permit Misc
3PL Permit Misc
Last Revision - 01.12.2022
Relocation - Non-Resident
Pharmacy Permit Misc
Wholesalers Permit Misc
Manufacturer Permit Misc
Medical Gas/DME Permit Misc
3PL Permit Misc
Last Revision - 04.27.2021
Remodel Application
Pharmacy Permit Misc
Remote Permit Misc
Wholesalers Permit Misc
Manufacturer Permit Misc
Medical Gas/DME Permit Misc
3PL Permit Misc
Last Revision - 04.27.2021
Request for License / Permit data
Technician License Misc
Intern License Misc
Pharmacist License Misc
Pharmacy Permit Misc
Remote Permit Misc
Wholesalers Permit Misc
Manufacturer Permit Misc
Medical Gas/DME Permit Misc
3PL Permit Misc
Last Revision - 12.24.2019
Verification of Licensure
Remote Permit Misc
Wholesalers Permit Misc
Manufacturer Permit Misc
Medical Gas/DME Permit Misc
3PL Permit Misc
Last Revision - web link
W-9 (2020)
Pharmacy Permit Misc
Remote Permit Misc
Wholesalers Permit Misc
Manufacturer Permit Misc
Medical Gas/DME Permit Misc
3PL Permit Misc
Last Revision - 06.05.2020
