FORMS

Beginning August 1, 2016, the Board will only accept current versions of Board of Pharmacy forms. Old forms will be returned (with payment) directly to the sender without processing. To ensure the most recent version, check the "Revised" date in the bottom right corner of each form.

On this page you'll find ALL Board of Pharmacy forms that are currently available online. Links on other web pages may direct you to these forms. Use the descriptions to find the right forms, which are available in pdf format and able to be electronically filled and signed online for submission to the Board office. Make sure you have included all fees and supporting documentation.

Applications for Pharmacists, Interns, and Technicians

 Form #      Form Name  Revision Date
     
LA-01  Pharmacist by Exam  04/17
LA-03 Pharmacy Intern  04/17
LA-14 Pharmacy Technician  10/16
   
LA-40  Change in Name or Contact Info  06/16
LA-50  Change in Employment  11/16
LA-60  Pharmacist - Reinstatement  02/17
LA-65  Pharmacist - Reinstatement after Revocation  02/17
LA-70  Technician - Reinstatement after Revocation  02/17
LA-80  Duplicate Pocket Card  02/17
LA-85  Duplicate Pharmacist Wall License  05/16
LA-100  Pharmacist Original Wall License  08/16











Facility and Business Applications

 Form #     Form Name  Revision Date
     
BA-02   Pharmacy (Resident)  02/17
BA-04  Manufacturer (in state)  02/17
BA-05  Distributor (cs, prescription drugs, and oxygen)  02/17
BA-06  Nonprescription Distributor  02/17
BA-07  Research/Teaching Institution (in state)  02/17
BA-08  Analytical Lab (in state)  02/17
BA-09  Ambulance or EMS (in state)  02/17
BA-10  Retail Dealer (in state)  02/17
BA-11  Health Department or Clinic (in state)  02/17
BA-12  Institutional Drug Room (in state)  02/17
BA-15  Sample Distributor  02/17
BA-16  Durable Medical Equipment  02/17
BA-22  Non-Resident Pharmacy  05/17
     
BA-50  Change in PIC/PIC Resignation  09/16





Supplemental Forms

S-100  Background Check  Waiver for KBI/FBI background check and instructions for Fingerprint Card 
S-150  Personal History  For individual applications with offense, disciplinary or criminal history
S-200  Continuing Education  For pharmacist applications for reinstatement
S-400  Intern Experience Hours  Log and Preceptor Certification for pharmacy intern experience hours
     
S-300  Disciplinary History  For facilities reporting disciplinary history 
S-310  Partnership Ownership  For facilities owned by a partnership or limited partnership 
S-320  LLC Ownership  For facilities owned by an LLC 
S-330  Corporate Ownership  For facilities owned by a public, private, or non-profit corporation 

Continuing Education - Requests for Approval

Miscellaneous Forms