Virginia Board of Pharmacy
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. To view PDF files you'll need the free Adobe Acrobat Reader.
Forms and Applications for Pharmacists
Guidance Document 110-2: Information for Applicants for a License as a Pharmacist - effective August 5, 2021
Applicants for Pharmacist License by Endorsement and Examination, to include graduates
of foreign schools of pharmacy, are now accepted online.
Click
here to begin the online application process.
NABP license transfer application for pharmacist endorsement (offsite link)
Timeline for pharmacist licensure
Guidance Document 110-17: Instructions for graduates of foreign schools of pharmacy - effective August 5, 2021
Reinstatement Application and Instructions for a Pharmacist License
Pharmacy Technician Trainees
Persons enrolled in a pharmacy technician training program must obtain a pharmacy technician trainee registration if they will be performing the duties of a pharmacy technician. Do NOT apply for a pharmacy technician trainee registration if you already hold a current active pharmacy technician registration OR have held a pharmacy technician registration that has been lapsed for less than 5 years.
Applications for Pharmacy Technician Trainee Registration are now exclusively accepted online. Click here to begin the online application process.
Pharmacy Technicians
Applications for Pharmacy Technician Registration are now exclusively accepted online. Click here to begin the online application process.
Reinstatement Application and Instructions for a Pharmacy Technician Registration
Affidavit by Free Clinic Director for Limited-Use Pharmacy Technician
Pharmacy Intern
Applications for Registration as a Pharmacy Intern are now accepted online. Click here to begin the online application process.
Affidavit of Practical Experience as a Pharmacy Intern
Forms for Pharmacies (In-State)
Pharmacy Closing Notification Form
Registration For A Pharmacy To Be A Collection Site For Donated Drugs
Registration For A Facility To Be An Authorized Collector For Drug Disposal
Application for Re-Inspection of a Facility
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
Outsourcing Facility Permit Application
Third-Party Logistics Provider Permit Application
Application for Re-Inspection of a Facility
Forms for Facilities (Out-of-State)
Non-Resident Pharmacy Registration Application
NOTES for Non-Resident Pharmacy Applicants:
- Refer to Guidance Document 110-38 Requirement for Non-resident Pharmacies to Submit Current Inspection Report
- Criteria for Current Inspection Report
Non-Resident Wholesale Distributor Registration Application
Non-Resident Medical Equipment Supplier Registration Application
Non-Resident Outsourcing Facility Registration Application
Non-Resident Manufacturer Registration Application
Non-resident Third Party Logistics Providers Application
Non-resident Warehouser Application
Forms for Physicians
Applications for a License for a Practitioner of the Healing Arts to Sell Controlled Substances are now accepted online. Click here to begin the online application process.
Facility Permit Application for a Practitioner of the Healing Arts to Sell Controlled Substances
Permitted Physician - please contact the Board for this type of application
Forms for Dispensing in NonProfit Facilities
Application for Limited Use Facility Dispensing Permit for NonProfit
Application for Limited Use Practitioner Dispensing License for NonProfit (Physician Assistants or Licensed Nurse Practitioners only)
Forms Relating to Controlled Substances Registration
Effective October 31, 2018, a Controlled Substances Registration is not required for a nursing home utilizing an automated dispensing system that is exclusively stocked with drugs that would be kept in a stat-drug box pursuant to 18VAC110-20-550 or an emergency drug kit pursuant to 18VAC110-20-540 and are solely administered for stat or emergency administration.
A Controlled Substance Registration is not required for an individual prescriber to be authorized to prescribe Schedule II-V drugs.
A Controlled Substance Registration is not required for any Nonresident facility registration.
Application for a Controlled Substances Registration for Various Entities (researchers, government officials, teaching institutions, outpatient surgery centers, EMS agencies, and others)
Inspection Forms
Pharmacy Routine Inspection Report
Pharmacy Inspection - New - Change of Location - Remodel
Medical Equipment Supplier Inspection Report
Controlled Substance Registration Inspection Report
Practitioners Selling Controlled Substances Inspection Report
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
License VerificationA Virginia licensee seeking to obtain a verification of his/her license, certification, or registration at no cost may do so by directing a board, employer, insurance provider or other interested parties to License Lookup. This content resource meets the accreditation standards for primary source verification from the top seven-accreditation organizations for healthcare professionals.
Name Change Form For Individuals
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
Notification of Distribution Cessation Due to Suspicious Orders
Pharmacist Attestation - CE credit for serving as a preceptor
Out-of-state temporary practitioner reporting form
Volunteer Practice Forms
Volunteer Practice Sponsor Form
Application for Registration for Volunteer Practice
Continuing Education (CE) Credit Form 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