Forms

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 05.12.2022
    Intern - Hours Report 10.22.2015
    Pharmacist - Immunization Application 08.01.2020
    Pharmacist - Renewal 08.24.2021
    Technician - Renewal 08.24.2021
    Technician - Reinstatement Application 08.24.2021
Miscellaneous License Forms  
    Discipline Acknowledgement 12.03.2019
    Duplicate / Replacement Request 10.15.2021
    Fee Waiver Request 10.26.2017
    Name Change Request 01.12.2022
    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