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Board of Pharmacy - Applications & Forms

 

 

Applications

• Authorization to Administer Drugs & Immunizations
• Continuing Education
• Mail Order Contact Lens Supplier
• Mail Order Prescription Pharmacy
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• Pharmacy Retake Exam
• Pharmacist Reciprocity/Endorsement
• Pharmacist Score Transfer
• Pharmacy
• PIC change for currently licensed
• Pharmacy Technician
• Pharmacy Technician Advanced
• Pharmacy Technician - Student Pharmacist - Introductory Pharmacy Practice Experience (IPPE)
• Pharmacy Technician - Student Pharmacist - Advanced Pharmacy Practice Experience (APPE)
• Pharmacy Technician - Student Graduate
• Reporting Authorized Persons
• Reporting Authorized Pharmacy Technicians
• Reporting of PIC for a New Pharmacy
• Reporting Termination as the PIC
• Wholesaler
• Wholesale Distributor

 

Forms

• Verification of Licensure Request Form
• Replacement License Request Form
• Emergency PIC Waiver
• Internship Affidavit
• Verification request form to send to other states
• Drug Theft-Loss-Unresolved Report
• Controlled Substance Destruction Log
• Preceptor Statement
• Pharmacy Inspection Report - (Word)
• Pharmacy Inspection Report - (pdf)
• Notice to all applicants regarding HIPDB/NPDB reports **
• Credit Card Authorization Form
  To authorize payment of fees by Visa or MasterCard.

** What is a HIPDB/NPDB Self Query?

 

If you cannot find what you are looking for, click HERE to send an e-mail message to the Board of Pharmacy.

 

Last Updated: November 13, 2009

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Featured

• Board of Pharmacy
• 35 State House Station
• Augusta, ME 04333-0035
• Phone: (207) 624-8620
• Fax: (207) 624-8637
• TTY: (888) 577-6690
• Program Staff

Proposed Rule Changes

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