Forms

Updated 12/13/2023

For additional information, please select the appropriate license/permit/registration to access the information page. 

  • ​These forms are not online applications and must be submitted by mail, or in-person, to the Kentucky Board of Pharmacy. Emailed applications may be submitted if utilizing an electronic signature.
  • These applications contain fillable fields that can be used to type in your response (note: not all fields have a fillable box and may require a response).
  • Applications submitted without your signature and date will not be processed and will be returned to you.​​

Professionals  

Individual Information Change Form

Pharmacist

Initial Application for Pharmacist Licensure​​​

Pharmacist Renewal Application​​

Inactive Pharmacist Application/Renewal

Application for Pharmacist Certification for Opioid Antagonist Dispensing​
Kentucky Reportable Disease Form​

   Yellow Fever Vaccination Center Application​

Pharmacist Intern 

Pharmacist Intern Application

Pharmacist Preceptor Affidavit

Pharmacist Internship Report

Academic Experience Affidavit 

Pharmacy Technician

Online Registration and Renewal

Pharmacy Technician Application

Pharmacy Technician Renewal Application

Charitable Pharmacy Technician Application

Charitable Pharmacy Technician Renewal Application

Continuing Education

Application for Pharmacist CE Approval

Application for Provider CE Approval   

 


 

Businesses

DEA 106 Form

Supplemental Information for Loss of Controlled Substance

Supplemental Information for Theft of Controlled Substance

Offsite Storage Request Form

Dual PIC Request Form

30 Day Temporary Dual PIC Request Form

PIC Change Form 

Kentucky Reportable Disease Form

A Guide to Facility Ownership Changes​

Opioid Antagonist Protocol​

Resident Pharmacy

Resident Pharmacy Application [New, Change of location/address, Change of ownership, Name change]​

Resident Pharmacy Renewal Application​

Non-resident Pharmacy

Non-resident Pharmacy Application [New, Change of location/address, Change of ownership, Name change] ​

Non-resident Pharmacy Renewal Application​

Clinical Practice Pharmacy

Clinical Practice Pharmacy Application [New, Change of location/address, Change of ownership, Name change]​​

Clinical Practice Pharmacy Renewal Application​

Non-resident Clinical Practice Pharmacy Application [New, Change of location/address, Change of ownership, Name change]​

​Non-resident Clinical Practice Pharmacy Renewal Application​

Medical Gas Pharmacy

Medical Gas Pharmacy Application [New, Change of location/address, Change of ownership, Name change]​

Medical Gas Pharmacy Renewal Application​

Non-resident Medical Gas Pharmacy Application [New, Change of lo​cation/address, Change of ownership, Name change]​

Non-resident Medical Gas Pharmacy Renewal Application​​

Charitable Pharmacy 

Charitable Pharmacy Application [New, Chage of location/address, Change of ownership, Name change]​

Charitable Pharmacy Renewal Application​

Non-resident Charitable Pharmacy Application [New, Change of location/address, Change of ownership, Name change]​​

Non-resident Charitable Pharmacy Renewal Application​​

Manufacturer [resident only]

Manufacturer Application [New, Change of location/address, Change of ownership, Name change] ​

Manufacturer Renewal Application​

Annual Summary of Monthly Audits of Dialysate Solutions or Devices

Wholesaler

Wholesaler Application [New, Change of location/address, Change of ownership, Name change]​

Wholesaler Renewal Application​

Third Party Logistics Provider

Third Party Logistics Provider Application [New, Change of location/address, Change of ownership, Name change]​

Third Party Logistics Provider Renewal Application​

Outsourcer Facility

Outsourcer Facility Application [New, Change of location/address, Change of ownership, Name change]

Outsourcer Facility Renewal Application 

Forms