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.

Instructions

Score transfer students – the college affidavit is on the website under Forms/Apps/Applications. You will need to print the form and have completed by your school before you begin the online process.

You must have a passport photo that you will upload during the online application process.

Unless you are an Auburn or Samford graduate you will need your driver’s license or birth certificate.

If you are not a citizen you will need proof of legal residence.

Application Type

Application Type	ReciprocityScore Transfer/Out-of-stateAuburn or Samford Pharmacy Graduate
Foreign Graduate

Demographics

* Last Name	* First Name	Middle Name	Maiden Name

* Address 1		Lot/Apt #

* City	* State	* Zip	* County

* Phone #	* Date of Birth	Cell Phone #	* Email

* Sex	* Are you a United States Citizen?	CPE Monitor #
MF	YesNo

Education Details

INFORMATION ABOUT PHARMACY EDUCATION

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INFORMATION ABOUT PRE-PHARMACY EDUCATION

^* Name of College :

^* Attended From(mon/year) :

^* Attended to(mon/year) :

Click Here to Add More

EXAM INFORMATION

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OTHER STATE LICENSE INFORMATION

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State

State

Regulatory Questions

1. Have you ever been convicted of a felony or misdemeanor, excluding minor traffic violations?	YesNo

2. Have you ever been arrested and/or convicted of violating any laws regulating controlled substances or prescription legend drugs?	YesNo

3. 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?	YesNo

4. Are there currently any pending investigations or charges regarding any license, permit or registration issued to you?	YesNo

5. Are you currently or have you ever been charged with a substance abuse violation or been in a substance abuse treatment program?	YesNo

6. 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 the Applicant or any Owner, Officer, Member, Director, Manager, Partner or by you?	YesNo

7. Have you or any entity you own/owned in whole or 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.	YesNo

8. Have you or any entity you own/owned in whole or part ever surrendered 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.	YesNo

9. 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 been sanctioned or subject to discipline in any way? If so attach copy of the discipline.	YesNo

Documents

Photo

Click Here To Upload 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

Date :

12/03/2020

* Controlled Substance

YesNo

(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 :

* Person's Name on Card:

*Select Debit or Credit :

*Card Type :

*Card # :

*Expiration Date :

*	Security Code :

* 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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