Pharmacist License Forms
NOTE: to expedite the application process as well as be more environmentally friendly, we ask that you please apply for any needed licenses online if at all possible (this does not apply to licenses 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 email our staff.
License Specific
Renewal Application
Technician License Specific
Pharmacist License Specific
Last Revision - 08.28.2020
Miscellaneous
Discipline Acknowledgement
Technician License Misc
Intern License Misc
Pharmacist License Misc
Last Revision - 12.03.2019
Documentation of Eligibility form for Licensure or Renewal
Technician License Misc
Intern License Misc
Pharmacist License Misc
Last Revision - 10.22.2015
Fee Waiver Request
Technician License Misc
Intern License Misc
Pharmacist License Misc
Last Revision - 10.26.2017
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
NAPLEX / MPJE Petition form
Pharmacist License Misc
Last Revision - 04.12.2019
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
Termination of Employment
Technician License Misc
Intern License Misc
Pharmacist License Misc
Last Revision - 10.22.2015