Pharmacist License

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    Verification

    SSN

    APPLICATION FEES ARE NON-REFUNDABLE. If the applicant fails to receive approval, the fee is retained for cost of processing.

    Demographics

    * Last Name * First Name Middle Name Maiden Name
    * Address 1 Lot/Apt #
    * City * State * Zip * County (If out of state, select Out of State)
    * Phone # * Date of Birth Cell Phone # * Email
    * Sex * Are you a United States Citizen? CPE Monitor #


    * Are you of Hispanic, Latino, or Spanish origin? (Select one)




    * Race (Please mark one or more boxes for your race.)





    * Are you an active duty military spouse or active-duty military?

    Education Details

    INFORMATION ABOUT PHARMACY EDUCATION

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    INFORMATION ABOUT PRE-PHARMACY EDUCATION

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    Regulatory Questions

    Have you ever been arrested or received a ticket/citation for any offense, excluding minor traffic violations?
    Have you ever been convicted (including a nolo contendere plea or guilty plea) of a felony or misdemeanor (other than minor traffic violations) whether or not sentence was imposed, suspended, expunged, or whether you were pardoned from any such offense?
    Are you presently under investigation or is there any disciplinary action pending against you by any federal or state licensing and/or enforcement authority for violation of any state or federal pharmacy, liquor, or drug laws?
    Do you currently have, or have you ever had, any condition or impairment including, but not limited to, substance or alcohol abuse or dependency that in any way affects your ability to practice pharmacy in a safe and competent manner?
    Has any final judgement been entered, or settlement reached resulting from a claim or action for damages caused by any error, omission, or negligence in the performance of any pharmacy or pharmaceutical professional services by you, including in your capacity as Owner, Officer, Member, Director, Manager, Partner of any pharmacy or pharmaceutical professional service entity?
    Have you or any entity you own/owned in whole, or in part ever been denied any license, permit, registration, certification or like authority by any board of pharmacy or any other occupational or regulatory board? If so, list state, type of license, etc., the occupation or profession and reason for denial.
    Have you or any entity you own/owned in whole, or in part ever surrendered, chose not to renew, or failed to renew any license, permit, registration, certification or like authority issued by any board of pharmacy or any other occupational or regulatory board? If so, list state, type of license, etc., the occupation or profession and reason for the surrender or failure to renew.
    Has any license, permit, registration, certification or like authority issued to you, or any entity you own/owned in whole or part, by any board of pharmacy or any other occupational or regulatory board ever been revoked, suspended, restricted, terminated, or otherwise been subject to disciplinary action (public or private) by any board of pharmacy or other state authority?
    Have you ever been licensed, permitted, or registered in any other state as a pharmacist, pharmacy technician or any other position requiring a license, permit or registration from a pharmacy board or requiring a permit involving dispensing controlled substances?


    Documents

    Photo
    (Please upload a 2x2 Passport size photograph that is less than 6 months old)
    NABP Reciprocity Application
    Please upload the entire NABP application as one document. Do not upload one page at a time.

    FPGEC Certificate

    Driver's License

    Birth Certificate

    Legal Presence

    College Affidavit

    Preview

    Affirm pay and submit

    I understand that I must comply with the provisions of the Alabama Practice Act, Rules of the Board and all other applicable statues and rules.
    I affirm that all information provided herein is true and correct and I recognize that providing false information may result in disciplinary action

    * E-Signature : Date : 06/07/2023 * Controlled Substance

    (Board of Pharmacy charge and Background Check charge, including a convenience fee, will appear on your statement with a description including IGOVSOL*.)
    *Examination Fee : *Permit Fee : *Controlled Substance Fee :
    *Transaction Fee : *Total : *Select Payment Type :
    * Person's Name on Card: *Select Debit or Credit : *Card Type :
    * Person's Name on Account: *Account Number: *Confirm Account Number:
    *Card # : *Expiration Date :
    * Security Code :
    *Routing Number: *Confirm Routing Number: * Billing Zip Code:
    (Board of Pharmacy charge and Background Check charge, including a convenience fee, will appear on your statement with a description including IGOVSOL*.)

     

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