Forms

Established 1903

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Forms & Applications

Guidelines / Instructions
	Applying for Pharmacist License (reciprocity instructions) (PDF)
	Applying for Pharmacist License (NAPLEX exam & score transfer instructions) (PDF)
	Applying for Technician License (PDF)
	Applying for Intern License (PDF)

	Applying for Pharmacy Permit
	Applying for Nonprescription Drug Retailer Permit
	Applying for Wholesaler Permit (PDF)


Applications
	Pharmacist License Application (reciprocity) (PDF)
	Pharmacist License Application (exam) (PDF)
	Technician License Application (PDF)
	Intern Application (PDF)
	License Renewal form (for individuals) (PDF)

	Pharmacy Permit Application (PDF)
	Wholesaler Permit Application (PDF)
	Nonprescription Drug Retailer Permit Application (PDF)
	Manufacturer Permit Application (PDF)
	Compressed Medical Gas Permit Application (PDF)
	Permit Location/Remodel Application (PDF)
	Permit Renewal form (for facilities) (PDF)

	Intern Preceptor Application (PDF)
	Pharmacist Immunization Application (PDF)
	Prescription Monitoring Program (PMP) Registration Application (PDF)
	Prescription Monitoring Program (PMP) Renewal form (PDF)


Other Forms
	Consumer Complaint form (PDF)
	FaxNet alert form (PDF)
	Address / Employment change form (PDF)
	Termination of Employment (PDF)
	Requests for Mailing Lists of Licensees/Permitees (PDF)
	License / Permit fee chart (PDF)
	Certificate Request / Replacement (PDF)
	Documentation of Eligibility form for Licensure or Renewal (PDF)
	Wholesale Surety Bond form (PDF)
	Management Agreement for Pharmacy change of ownership (PDF)
	Intern Hours Report form (PDF)
	Arizona Preceptor Letter (PDF)
	DEA form 224 (Registration Application)
	DEA form 41 (Registrants Inventory of Drugs Surrendered)
	DEA form 106 (Theft or Loss of Controlled Substances)
	Controlled Substances Inventory Book (PDF)

License / Permit Verification

License / Permit Online Applications

License Renewal Form
(for individuals) (PDF)

Permit Renewal Form
(for facilites) (PDF)

Online Renewals are
available 8/24 - 10/31
Click here to renew your license or permit

2010 Renewal Fees (PDF)

July 14, 2010
Complaint Review Committee
(PDF)

July 15, 2010
Board Meeting Agenda
(PDF)

July 15, 2010
Board Meeting Minutes
(PDF)
(Draft Minutes Require Board Approval at Next Scheduled Meeting)