Forms

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

Professionals  

Individual Information Change Form

Pharmacist

Application for Pharmacist Examination

Pharmacist Renewal Application

Inactive Pharmacist Application/Renewal

Application for Pharmacist Certification for Naloxone Dispensing 

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

PIC Change Form 

Kentucky Reportable Disease Form

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 [resident only]

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

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

Charitable Pharmacy 

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

Chariable Pharmacy Renewal Application 

Manufacturer [resident only]

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

Manufacturer Renewal Application

Wholesale Distributor

Wholesale Distributor Application [New, Change of location/address, Change of ownership, Name change]

Wholesale Distributor 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