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Applications & Forms


Address of record

Section 54.1-2400.02.B of the Code of Virginia requires the Department of Health Professions (DHP) to collect an official address of record from each health professional to be used by DHP for agency purposes. The Code also requires DHP to provide an opportunity for a health professional to provide a second address for the purpose of public dissemination. If there is no second (public) address provided, the official address of record will be used as the public address for the purpose of public dissemination. This is applicable to all pharmacists, pharmacy interns, and pharmacy technicians. If the individual would prefer that his/her address of record remain confidential, then an alternative public address must be provided to DHP. (Note: the License Lookup feature on the DHP public website does not contain the full address. However, public addresses are available by contacting Virginia Interactive Premium Service or the Board.) An individual is not required to submit a place of residence for either the official address of record or the public address. A post office box or a practice location is acceptable. This is not true for facilities licensed by the Board of Pharmacy. The address of record for facilities must be the actual physical location of the facility.

Changes to either address may be made at the time of renewal or at any time by written notification to the Board. Changes to the address of record may also be made at any time by accessing your licensure information through the online system. Any change that is made to one of the addresses does not automatically update the other address. Address information should be kept current for the address of record and the public address (if different from the address of record) at all times.

Facilities licensed by the Board may only make changes to their address by filing an application with the Board prior to any change, and such change typically requires an inspection and approval of the new location.

The below documents are in Microsoft Word format. If you do not have Microsoft Word, you can get the Microsoft® Word Viewer 97/2000 to view and print documents.

Forms and Applications for Pharmacists

Guidance Document 110-2:  Information for Applicants for a License as a Pharmacist - September 2009

Applicants for Pharmacist License by Examination, to include graduates of foreign schools of pharmacy are now accepted online. Click here to begin the online application process.

 

Application for Pharmacist License by Endorsement (reciprocity from another state) see NABP website, Licensure, License Transfer Application (Offsite Link)

Guidance Document 110-17:  Instructions for graduates of foreign schools of pharmacy - revised December 12, 2013

Instructions and Application to Reinstate or Reactivate a Pharmacist License

 

Pharmacy Intern

Applications for Registration as a Pharmacy Interns are now accepted online. Click here to begin the online application process.

Pharmacy Intern Application for Graduate of Foreign School of Pharmacy

Affidavit of Practical Experience as a Pharmacy Intern

Application for Reinstatement of Registration as a Pharmacy Intern

 

Pharmacy Technicians

Applications for Pharmacy Technician Registration are now exclusively accepted online. Click here to begin the online application process.

Instructions and Application to Reinstate a Pharmacy Technician Registration

Application for Registration as a Limited-Use Pharmacy Technician (for use exclusively in a free clinic)

Affidavit by Free Clinic Director for Limited-Use Pharmacy Technician

 

Pharmacy Technician Training Programs

Application for Approval of a Pharmacy Technician Training Program

 

Forms for Pharmacies (In-State)

Pharmacy Permit Application

Pharmacy Closing Notification Form

Registration For A Pharmacy To Be A Collection Site For Donated Drugs

 

Forms for Other Facilities (In-State)

Medical Equipment Supplier Permit Application

Restricted Manufacturer Permit Application (for OTC drugs or transfilling medical oxygen)

Non-Restricted Manufacturer Permit Application

Wholesale Distributor License Application

Limited-Use Wholesale Distributor License Application

Warehouser Application

 

Forms for Facilities (Out-of-State)

Non-Resident Pharmacy Registration Application

NOTES for Non-Resident Pharmacy Applicants:

Non-Resident Wholesale Distributor Registration Application

Medical Equipment Supplier Permit Application

Limited-Use Wholesale Distributor License Application

Forms for Physicians

Application for a License for a Practitioner of the Healing Arts to Sell Controlled Substances

Permitted Physician Application

Forms Relating to Controlled Substances Registration

Application for a Controlled Substances Registration for Various Entities (researchers, government officials, teaching institutions, outpatient surgery centers, EMS agencies, and others)

 

DEA Forms

Information regarding the filing of a Theft/Loss Report - DEA Form 106

Click here to link to DEA's website to obtain a copy of Form 106 - Theft/Loss Report

 

Miscellaneous

Application for Board Approval of a Continuing Education Program for CE credit for pharmacists in Virginia

Application for Approval of an Innovative (Pilot) Program

Application for Approval of ACPE Pharmacy School Course(s) for Continuing Education Credit

Application for Approval of Repackaging Training Program


Volunteer Practice Forms

Volunteer Practice Sponsor Form

Application for Registration for Volunteer Practice

Monitoring for Board Orders

Important Information About Your Board of Pharmacy Order

Self Report – Pharmacist or Pharmacy Technician

Performance Evaluation Form – Pharmacist or Pharmacy Technician