Forms

NOTE: Board staff recommends submitting these forms electronically to [email protected], as paper applications and forms take longer to process. 

 

License Specific Forms Last Revision
    Immunization Application 05.12.2022
    Intern - Hours Report 10.22.2015
    Pharmacist - 2024 Renewal (Use this application starting September 3, 2024) 08.27.2024
    Technician - 2024 Renewal (Use this application starting September 3, 2024) 08.27.2024
    Technician - Reinstatement Application 05.17.2023
   Verification Of Licensure Form 03.21.2023
Miscellaneous License Forms  
    Discipline Acknowledgement 12.03.2019
    Duplicate / Replacement Request 03.14.2024
    Fee Waiver Request 10.26.2017
    Name Change Request 03.14.2024
    NAPLEX / MPJE Petition form 04.12.2019
    Request for License / Permit data 05.20.2022
    Termination of Employment 05.20.2022
    Verification of Licensure web link