Forms

The Board will only accept current TYPED versions of Board of Pharmacy forms. Old forms or handwritten 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
Facility and Business Applications
Supplemental Forms
Continuing Education - Request for Approval
Miscellaneous Forms

Applications for Pharmacists, Interns, and Technicians

 Form #      Form Name  Revision Date
     
LA-01R  LA-01R Pharmacist by Reciprocity-Transfer  05/2021
LA-01E  Pharmacist by Exam (NOT Transfer or Reciprocity)  05/2021
LA-03 Pharmacy Intern  05/2021
LA-14 Pharmacy Technician  01/2022
   
LA-40 Change in Name or Contact Info  07/2018
LA-50 Change in Employment  07/2018
LA-55 Change in Pharmacist License Status  07/2018
LA-60 Pharmacist - Reinstatement  12/2021
LA-65 Pharmacist - Reinstatement after Revocation  12/2021
LA-70 Technician - Reinstatement after Revocation  01/2022
LA-75 Technician Certification Extension Request  04/2019
LA-80 Duplicate Pocket Card  07/2018
LA-85 Duplicate Pharmacist Wall License  07/2018
LA-100 Pharmacist Original Wall License  07/2018

Facility and Business Applications

 Form #     Form Name  Revision Date
     
BA-02   Pharmacy (Resident)  06/2019
BA-04  Manufacturer  05/2021
BR-04  Manufacturer 2021 Renewal  05/2021
BA-05  Distributor (cs, prescription drugs, oxygen, & devices)  03/2020
BA-06  Nonprescription Drug Distributor  03/2020
BA-07  Research/Teaching Institution (in state)  02/2017
BA-08  Analytical Lab (in state)  02/2017
BA-09  Ambulance or EMS (in state)  02/2017
BA-10  Retail Dealer  12/2017
BA-11  Health Department or Clinic (in state)  02/2017
BA-12  Institutional Drug Room (in state)  06/2019
BA-15  Sample Drug Distributor  06/2019
BA-16  Durable Medical Equipment  12/2021
BA-20  Outsourcing Facility  03/2020
BA-21  Automated Drug Delivery System in LTCF  12/2020
BA-22  Non-Resident Pharmacy  06/2019
BA-23  Third-party Logistics Provider  03/2020 
BA-25  Nonprescription Third-Party Logistics Provider  03/2020 
     
BA-50  Change in PIC/PIC Resignation  01/2022
BA-55  Change in Designated Representative (or other)  03/2020 
BA-60  BA-60 Facility Closure Notice  07/2018

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-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 
 S-340  $25,000 Surety Bond Form  $25,000 surety bond form for wholesale distributors
 S-345  $100,000 Surety Bond Form  $100,000 surety bond form for wholesale distributors
S-350   Non-Resident Supplement For non-resident pharmacies, distributors, nonprescription distributors, and DME.  
S-400  Intern Experience Hours  Log and Preceptor Certification for pharmacy intern experience hours
S-500  Kansas Hospital Electronic Supervision Form  For hospitals receiving remote supervision
     
 K-10 K-10 Notice of Exemption from Reporting  For pharmacies that do not dispense controlled substances
     
 N-100 Automated Drug Delivery System Notice: Installation or Removal This form is for a pharmacy, located and registered in Kansas, who will have an automated drug delivery system located in that pharmacy, institutional drug room, or medical care facility.
For LTCF Automation: See BA-21
 N-300 Self-Inspection Attestation Form
This form is for non-resident pharmacies or facilities unable to obtain a home-state inspection in the designated time frame due to COVID-19.

Continuing Education - Requests for Approval

Miscellaneous Forms