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Arizona State Board of Pharmacy Logo
Arizona State Board of Pharmacy
Protects the health, safety and welfare of the citizens of Arizona
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Forms

NOTE:  to expedite the application process as well as be more environmentally friendly, we ask that you please apply for any needed licenses or permits online if at all possible (this does not apply to Technician Reinstatement requests or licenses or permits with expiration dates prior to 10/31/2017 – these cannot be done online). If you require a hardcopy version of any applications not listed below, please contact Sonia Carrillo at [email protected].

 

Applications

 

Document

Document Type

Last Revision

Licenses
(individuals)


Pharmacist Renewal
Technician Renewal


Technician Application - Reinstatement (revision in progress)
 


PDF
PDF

PDF

 


08.30.2019
08.30.2019


---
 

Permits
(facilities)


Pharmacy renewal
Wholesaler renewal
Manufacturer renewal
Medical Gas/DME renewal
3PL renewal


Pharmacy Application - Kiosk & Remote Dispensing
Resident Relocation/Remodel Application
Non-Resident Relocation Application


PDF
PDF
PDF
PDF
PDF

PDF
PDF
PDF

 


08.30.2019
08.30.2019
08.30.2019
08.30.2019
08.30.2019

12.12.2018

03.23.2018
03.23.2018

 

Other


Certificate of Free Sale / Good Manufacturing Practice
Immunization Application

 


PDF
PDF

 


02.01.2017
08.01.2011

 

 

Miscellaneous Forms

 

Document

Document Type

Last Revision

 

Consumer Complaint
Discipline Acknowledgement

Duplicate / Replacement Request
DEA form 41 (Registrants Inventory of Drugs Surrendered)
DEA form 106 (Theft or Loss of Controlled Substances)
DEA form 224 (Registration Application)
Deviation Request
Documentation of Eligibility form for Licensure or Renewal
Fee Waiver Request
Intern Hours Report
Management Agreement for Pharmacy change of ownership
Name Change Request
NAPLEX / MPJE Petition Form
Pharmacy - Closure Notification Form
Pharmacy - Opening Checklist
Tuberculosis Treatment pharmacy-reporting-form
Request for license/permit lists
Termination of Employment
W-9
Written Verification Request

PDF
PDF
PDF
PDF
Web
Web
PDF
PDF
PDF
PDF
PDF
PDF
PDF
PDF
PDF
PDF
PDF
PDF
PDF
PDF

08.31.2014
12.03.2019
05.08.2017
10.22.2015
-
-
02.16.2019
10.22.2015
10.26.2017
10.22.2015
10.22.2015
11.29.2017
04.12.2019
07.05.2018
12.13.2018
03.01.2019
02.22.2019
10.22.2015
11.15.2018
02.06.2018

Arizona State Seal
Contact Us
Board of Pharmacy
1616 W. Adams St., Suite 120
Phoenix, AZ 85007
Find in Google Maps
Phone: (602) 771-2727
Fax: (602) 771-2749
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