Forms & Applications
Pharmacists
Application for New Pharmacist License
010 ~ Application for New Pharmacist License (updated 08/20)
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
010-SWP ~ Application for Special Work Permit for State of Emergency
017 ~ Application for New Collaborative Drug Therapy Managaement (CDTM) Registration
019 ~ Application for New Medication Administration Registration (updated 2020-0701)
062 ~ Affidavit of Acknowledgement & Acceptance of Responsibility by Pharmacist-in-Charge (updated 2020-0420)
150 ~ Application for Therapeutic Marijuana (TM) Designation
Applications for Renewal of Existing Pharmacist License
012-L ~ Application for Late Renewal of Pharmacist License for Year 2020
012 ~ Application for Renewal of Pharmacist License for Year 2021
012-L ~ Application for Late Renewal of Pharmacist License for Year 2021
012-G-L ~ Application for Late Renewal of Pharmacist Gold Certificate for Year 2020
012-G ~ Application for Renewal of Pharmacist Gold Certificate for Year 2021
012-G-L ~ Application for Late Renewal of Pharmacist Gold Certificate for Year 2021
012-M-L ~ Application for Late Renewal of Military Pharmacist License for Year 2020
012-M ~ Application for Renewal of Military Pharmacist License for Year 2021
012-M-L ~ Application for Late Renewal of Military Pharmacist License for Year 2021
012-MS-L ~ Application for Late Renewal of Pharmacist License for Military Spouse for Year 2020
012-MS ~ Application for Renewal of Pharmacist License for Military Spouse for Year 2021
012-MS-L ~ Application for Late Renewal of Pharmacist License for Military Spouse for Year 2021
012-VI-L ~ Application for Late Renewal of Pharmacist License on Voluntary Inactive Status for Year 2020
012-VI ~ Application for Renewal of Pharmacist License on Voluntary Inactive Status for Year 2021
012-VI-L ~ Application for Late Renewal of Pharmacist License on Voluntary Inactive Status for Year 2021
012-GVI ~ Application for Renewal of Pharmacist Gold Certificate on Voluntary Inactive Status for Year 2020
012-GVI ~ Application for Renewal of Pharmacist Gold Certificate on Voluntary Inactive Status for Year 2021
Applications for Renewal of Existing Pharmacist Privileges
026 ~ Application for Renewal of Medication Administration Registration (updated 2020-0701)
Forms for General Use
090 ~ Notice of Change in Mailing Address
091 ~ Notice of Name Change
092 ~ Notice of Pharmacy Employment
201 ~ Product Order Form - Duplicate Credential
204 ~ Product Order Form - Pharmacist's Original Certificate
205 ~ Product Order Form - Pharmacist's Silver Certificate
