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Kentucky Board of Pharmacy Kentucky Board of Pharmacy Kentucky Board of Pharmacy

Applications and Forms

Use the following links to access the appropriate applications to license, renew or make changes to existing permits, licenses or registrations.

Pharmacy

Resident Pharmacy Application [PDF - 55KB] - Use this application for new resident pharmacy permits, or location, address, ownership and name changes for existing resident pharmacy permits.

Non-resident Pharmacy Application [PDF - 155KB] - Use this application for new non-resident pharmacy permits, or location, address, ownership and name changes for existing non-resident pharmacy permits.

Medicinal Gas Permit Application [PDF - 58KB] - Pharmacist Consultant not required for out-of-state facilities.
Use this application for new medicinal gas pharmacy permits, or location, address, ownership and name changes for existing medicinal gas pharmacy permits.

Clinical Practice Pharmacy Application [PDF - 57KB] - Use this application for new clinical practice pharmacy permits, or location, address, ownership and name changes for existing clinical practice pharmacy permits.
 
Resident Pharmacy Renewal Application [PDF - 37KB] - $100.00

Non-Resident Pharmacy Renewal Application - $100.00

Medicinal Gas Permit Renewal [PDF - 48KB] - $100.00

Clinical Practice Pharmacy Renewal Application [PDF - 56KB] - $100.00

PIC change form [PDF - 96KB] - $5.00 

Telephone Inspection Form [PDF - 33KB]

Wholesalers/Manufacturers

Wholesaler/Manufacturer Application [PDF - 57KB] - Use this application for new wholesale distributor licenses or new manufacturer permits, or location, address, ownership and name changes for existing licenses or permits.

Wholesaler/Manufacturer Renewal Application [PDF - 43KB] - $100.00 fee

Pseudoephedrine Log Waiver Request Form [PDF - 53KB]

Pharmacists
Pharmacist Interns

Form I - Pharmacist Intern Application [PDF - 45KB] - Once you have completed this application, please print, date and sign then submit to the Board office along with a passport sized photo, letter of acceptance into a college of pharmacy [a copy of your FPGEC certificate for foreign graduates] and payment.

Form II - Pharmacist Preceptor Affidavit [PDF - 46KB]

Form III - Pharmacist Internship Report [PDF - 30KB]

Form IV - Academic Experience Affidavit

Pharmacy Technicians
Home Medical Equipment License
Continuing Education Approval Form
CE approval form [PDF - 62KB]

 

Facility Name Changes
 

The Board requires notification of name changes within thirty days. If a change occurs during the renewal period, you may write the change directly on the application for renewal. The change may also be submitted in writing. If a name change occurs outside the renewal period, a check for $5.00 for the issuance of a new license (made payable to Kentucky State Treasurer) must accompany the request. All name changes must be supported with  an official court document authorizing the name change.

 

Download Adobe Acrobat
 

Note: These documents are in Adobe .PDF format. To view, download, or print these documents, you must have Adobe Acrobat Reader. Follow this link to download a free copy of the Abode Acrobat Reader. External Link - You are now leaving the .gov domain.

 

Last Updated 7/25/2013
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