Forms & Applications
Pharmacists
Application for New Pharmacist License
010 ~ Application for New Louisiana Pharmacist License (revised 10-2018)
010-NR ~ Certification of Graduation from ACPE-Accredited College/School of Pharmacy Located Outside Louisiana (for use by graduates from other states seeking licensure by examination or score transfer, but not by license transfer or reciprocity)
Applications for New Pharmacist Privileges
017 ~ Application for New Collaborative Drug Therapy Managaement (CDTM) Registration
019 ~ Application for New Medication Administration Registration (updated 2017-0901)
062 ~ Affidavit of Acknowledgement & Acceptance of Responsibility by Pharmacist-in-Charge
150 ~ Application for Therapeutic Marijuana (TM) Designation
Applications for Renewal of Existing Pharmacist License
012 ~ Application for Renewal of Pharmacist License for Year 2019
012-L ~ Application for Late Renewal of Pharmacist License for Year 2019
012-G ~ Application for Renewal of Pharmacist Gold Certificate for Year 2019
012-G-L ~ Application for Late Renewal of Pharmacist Gold Certificate for Year 2019
012-M ~ Application for Renewal of Military Pharmacist License for Year 2019
012-M-L ~ Application for Late Renewal of Military Pharmacist License for Year 2019
012-MS ~ Application for Renewal of Pharmacist License for Military Spouse for Year 2019
012-MS-L ~ Application for Late Renewal of Pharmacist License for Military Souse for Year 2019
012-VI ~ Application for Renewal of Pharmacist License on Voluntary Inactive Status for Year 2019
012-VI-L ~ Application for Late Renewal of Pharmacist License on Voluntary Inactive Status for Year 2019
012-GVI ~ Application for Renewal of Pharmacist Gold Certificate on Voluntary Inactive Status for Year 2019
Applications for Renewal of Existing Pharmacist Privileges
026 ~ Application for Renewal of Medication Administration Registration
Forms for General Use
090 ~ Notice of Change of Mailing Address or Employment
091 ~ Notice of Change of Name
201 ~ Product Order Form - Duplicate Credential
204 ~ Product Order Form - Pharmacist's Original Certificate
205 ~ Product Order Form - Pharmacist's Silver Certificate
