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 Forms | Last Revision |
Intern - Immunization Application | 08.01.2020 |
Intern - Hours Report | 10.22.2015 |
Pharmacist - Immunization Application | 08.01.2020 |
Pharmacist - Renewal | 08.28.2020 |
Technician - Renewal | 08.28.2020 |
Technician - Reinstatement Application | 11.02.2020 |
Miscellaneous License Forms | |
Discipline Acknowledgement | 12.03.2019 |
Duplicate / Replacement Request | 05.08.2017 |
Documentation of Eligibility form for Licensure or Renewal | 10.22.2015 |
Fee Waiver Request | 10.26.2017 |
Name Change Request | 11.29.2017 |
NAPLEX / MPJE Petition form | 04.12.2019 |
Request for License / Permit data | 12.24.2019 |
Termination of Employment | 10.22.2015 |
Verification of Licensure | web link |