Quick Hits
Applications and Forms
Complaint Form
The complaint form may be completed online and then printed or you may print the form and complete by hand. This form can not be submitted electronically. Please forward the completed form to the board office. Complaint Form
You may also submit your complaint electronically through the Board's ON-LINE COMPLAINT FORM.
| Applications and Forms | |
|---|---|
Pharmacist Licensure Exam |
Download |
Retake Application for Pharmacist Licensure Examination |
Download |
Intern Pharmacist |
Download |
Intern Hours Affidavit
|
Download |
Pharmacy Technician |
Download |
Foreign Graduate |
Download |
Pharmacy |
|
|
Community Pharmacy
|
Download |
|
Hospital Pharmacy
|
Download |
|
Sterile Compounding
|
Download |
|
Non-Resident
|
Download |
|
Non-Resident Sterile Compounding
|
Download |
|
Change of Pharmacist in Charge
|
Download |
Clinic |
Download |
Wholesaler |
Download |
Non-Resident Wholesaler (Out of State Distributor) |
Download |
Designated Representative (Exemptee) |
|
|
Designated Representative Wholesaler/Non-Resident Wholesaler
|
Download |
|
Designated Representative Vet Retailer
|
Download |
|
Change of Designated Representative-in-Charge
|
Download |
Renewal Forms |
|
|
Pharmacist
|
Download |
|
Pharmacy Technician
|
Download |
|
Designated Representative (Exemptee)
|
Download |
|
Designated Representative Vet Retailer (Exemptee)
|
Download |
|
Pharmacy/Clinic
|
Download |
|
Wholesale/Out of State Distributor
|
Download |
|
Hypodermic Needle and Syringe
|
Download |
|
Veterinary Food-Animal Drug Retailer
|
Download |
Change of Permit |
|
|
Change of Permit - Pharmacy, Clinic
|
Download |
|
Change of Permit - Wholesaler, Vet Retailer, Hypodermic
|
Download |
Hypodermic Needle and Syringe Permit |
Download |
Veterinary Food-Animal Drug Retailer |
Download |
Application to Store Pharmacy Records Offsite |
Download |
Discontinuance of Business form |
Download |
Self-Assessment Forms |
|
|
Community Pharmacy
|
Download |
|
Hospital Pharmacy
|
Download |
|
Sterile Compounding
|
Download |
|
Wholesaler
|
Download |
Change of Address(Personal Licenses Only) |
Download |
Duplicate/Replacement License Request form |
Download |
Retired Pharmacist License Application |
Download |
CE Petition for Pharmacists |
Download |
Patient Activity Report (PAR) |
|
|
Pharmacist Request for Patient Activity Report (BNE 1177)
|
Download |
|
Prescriber Request for Patient Activity Report (BNE 1176)
|
Download |
