Forms


Forms


The Board office is not currently accepting walk-ins. Paper applications and applicable payments must be submitted by mail.
 

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 10/31/2019 – these cannot be done online). If you require a hardcopy version of any applications not listed below, please contact our office.

License Specific FormsLast Revision
    Intern - Immunization Application08.01.2020
    Intern - Hours Report10.22.2015
    Pharmacist - Immunization Application08.01.2020
    Pharmacist - Renewal08.28.2020
    Technician - Renewal08.28.2020
    Technician - Reinstatement Application11.02.2020
Miscellaneous License Forms 
    Discipline Acknowledgement12.03.2019
    Duplicate / Replacement Request05.08.2017
    Documentation of Eligibility form for Licensure or Renewal10.22.2015
    Fee Waiver Request10.26.2017
    Name Change Request11.29.2017
    NAPLEX / MPJE Petition form04.12.2019
    Request for License / Permit data12.24.2019
    Termination of Employment10.22.2015
    Verification of Licensureweb link

 

Permit Specific FormsLast Revision
    3PL - Renewal08.28.2020
    Manufacturer - Application for Certificate of Free Sale / GMP02.01.2017
    Manufacturer - Renewal08.28.2020
    Medical Gas / DME - Renewal08.28.2020
    Pharmacy - Application for Kiosk & Remote Dispensing12.12.2018
     Pharmacy - Management Agreement for Ownership Change10.22.2015
    Pharmacy - Notification to Close07.05.2018
     Pharmacy - Opening Checklist12.13.2018
    Pharmacy - Renewal for Kiosk & Remote Dispensing08.28.2020
    Pharmacy - Renewal08.28.2020
     Pharmacy - Reporting Tuberculosis Treatment03.01.2019
    Wholesaler - Renewal08.28.2020
Miscellaneous Permit Forms 
    DEA - form 41 (Registrants Inventory of Drugs Surrendered)10.22.2015
    DEA - form 106 (Theft or Loss of Controlled Substances)web link
     DEA - form 224 (Registration Application)web link
     Deviation Requestweb link
     Duplicate / Replacement Request05.08.2017
    Name Change Request06.08.2020
    Relocation - Non-Resident03.23.2018
    Relocation - Resident03.23.2018
    Request for License / Permit data12.24.2019
    Verification of Licensureweb link
    W-9 (2020)06.05.2020

 

AZ State Legislature


 

AZ Open Books



 

OCCUPATIONAL REGULATION
Pursuant to section 41-1093.01, Arizona Revised Statutes, an agency shall limit all occupational regulations to regulations that are demonstrated to be necessary to specifically fulfill a public health, safety or welfare concern. Pursuant to sections 41-1093.02 and 41-1093.03, Arizona Revised Statutes, you have the right to petition this agency to repeal or modify the occupational regulation or bring an action in a court of general jurisdiction to challenge the occupational regulation and to ensure compliance with section 41-1093.01, Arizona Revised Statutes.