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)  09/2023
LA-03 Pharmacy Intern  09/2023
LA-14 Pharmacy Technician  09/2023
LA-40 Online Account Update
Change in Name or Contact Info
LA-50 Online Account Update
Change in Employment
LA-55 Change in Pharmacist License Status  07/2018
LA-60 Pharmacist - Reinstatement  09/2022
LA-65 Pharmacist - Reinstatement after Revocation  09/2022
LA-70 Technician - Reinstatement after Revocation  09/2023
LA-75 Technician Certification Extension Request  11/2022
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)  06/2023
BA-04  Manufacturer  09/2022
BA-05  Distributor (cs, prescription drugs, oxygen, & devices)  09/2022
BA-06  Nonprescription Drug Distributor  12/2022
BA-07  Research/Teaching Institution  05/2022
BA-08  Analytical Lab  05/2022
BA-09  Ambulance or EMS (in state)  03/2022
BA-10  Retail Dealer  08/2023
BA-11  Health Department or Clinic (in state)  06/2023
BA-12  Institutional Drug Room (in state)  06/2023
BA-15  Sample Drug Distributor  03/2022
BA-16  Durable Medical Equipment  03/2022
BA-20  Outsourcing Facility  06/2023
BA-21  Automated Drug Delivery System in LTCF  06/2023
BA-22  Non-Resident Pharmacy  01/2022
BA-23  Third-party Logistics Provider 12/2022 
BA-25  Nonprescription Third-Party Logistics Provider 12/2022 
BA-50  Change in PIC/PIC Resignation  12/2023
BA-55  Change in Designated Representative (or other)  03/2020 
BA-60  BA-60 Facility Closure Notice  09/2022

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-400 N-400 Participation Form-Donating Entity This form is for medical care facilities, mail service pharmacies and adult care homes intending to participate in the Utilization of Unused Medications program by donating medications.
 N-450 N-450 Participation Form-Clinics & Qualifying Centers This form is for clinics and qualifying centers intending to participate in the Utilization of Unused Medications program by accepting medications.

Continuing Education - Requests for Approval

Miscellaneous Forms