Pharmacist License




Application Type

Application Type


Last Name First Name Middle Name Maiden Name
Address1 Lot/Apt # City State
Zip County Phone # Date of Birth
Cell Phone # Email Sex CPE Monitor #
Are you a United States Citizen?
Are you of Hispanic, Latino, or Spanish origin? : Race :
Are you an active duty military spouse or active-duty military? :

Education Details

Regulatory Questions


Photo Click Here To Upload Photo
NABP Reciprocity Application

FPGEC Certificate

Driver's License

Birth Certificate

Legal Presence

College Affidavit


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

Controlled Substance Waiver: I am hereby requesting the Board to issue only a license or permit and that no activities requiring a controlled substance registration will be performed during the referenced period. I understand that providing a false statement or engaging in any activity requiring a controlled substance registration may result in discipline.

Controlled Substance Order ID :
E-Signature : Date :