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

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

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