Louisiana Board of Pharmacy

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Forms & Applications

Pharmacists


Application for New Pharmacist License

010 ~ Application for New Louisiana Pharmacist License

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

062 ~ Affidavit of Acknowledgement & Acceptance of Responsibility by Pharmacist-in-Charge



Applications for Renewal of Existing Pharmacist License 

012 ~ Application for Renewal of Pharmacist License for Year 2016

012-L ~ Application for Late Renewal of Pharmacist License for Year 2016


012-G ~ Application for Renewal of Pharmacist Gold Certificate for Year 2016

012-G-L ~ Application for Late Renewal of Pharmacist Gold Certificate for Year 2016


012-M ~ Application for Renewal of Military Pharmacist License for Year 2016

012-M-L ~ Application for Late Renewal of Military Pharmacist License for Year 2016


012-VI ~ Application for Renewal of Pharmacist License on Voluntary Inactive Status for Year 2016

012-VI-L ~ Application for Late Renewal of Pharmacist License on Voluntary Inactive Status for Year 2016


012-GVI ~ Application for Renewal of Pharmacist Gold Certificate on Voluntary Inactive Status for Year 2016



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