Department of Consumer Affairs Board of Pharmacy

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
Intern Pharmacist Extension Request
Download
Pharmacy Technician
Download
Foreign Graduate
Download
Pharmacy
Community Pharmacy
Download
Hospital Pharmacy
Download
Centralized Hospital Packaging 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
Pharmacist Renewal Live Scan Form
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 Self Assessment (17M-13, Rev. 01/11) 
Download
17M-13 With Updates (2013)
Download
Compounding Self-Assessment (17M-39, Rev. 02/12)
Download
17M-39 With Updates (2013)
Download
Hospital Outpatient Pharmacy Self-Assessment (17M-13, Rev. 01/11)
Download
17M-13 With Updates (2013)
Download
Hospital Self-Assessment (17M-14, Rev. 01/11)
Download
17M-14 With Updates (2013)
Download
Wholesaler Self-Assessment (17M-26, Rev. 01/11)
Download
17M-26 With Updates (2013)
Download
Change of Address (Personal Licenses Only)
Download
Duplicate/Replacement License Request form
Download
Retired Pharmacist License Application
Download
CE Petition for Pharmacists
Download

*Earlier this year, the board submitted to the Office of Administrative Law revised self-assessment forms that incorporated statutory and regulatory updates since 2011.  This rulemaking was withdrawn from OAL, and a formal rulemaking will be initiated later this year.  However, the revised (2013) forms MAY be used by a pharmacist or designated representative in charge if desired.

Current regulations require that the version(s) last approved by OAL be completed; however, the board will accept completion of either the OAL-approved versions OR the versions that were revised in 2013 (which will be the subject of a future formal rulemaking).