Forms

Forms shown below may be downloaded in Adobe Acrobat Format, and some forms may be filled out online and then printed or downloaded. If you do not have Adobe Acrobat Reader, you may download it at no cost from Adobe Acrobat.

Duplicate License Request - Individual Change Form - License Verification Request Form
Duplicate Certification or Small Card Request Form Individual Change Form: Employment, Address, or Name Change License Verification Request Form
Continuing Education & Training
Pharmacists: CE Approval Form for Non-ACPE-Approved Program Attendees Certification of Completion of Continuing Education Technicians: CE Approval Form for Non-ACPE-Approved Program Attendees Certification of Completion of Continuing Education Program Providers: Application to Become a Minnesota Approved Continuing Education Provider Renewal Application for Approved Continuing Education Providers Approved Providers Application for New Continuing Education Program Single Program Continuing Education Application
Internship Information
Hours Transfer Request Notice of Employment Progress Report/Affidavit of Internship Training Standards for Traditional Dispensing Internships
Pharmacy
DEA Form 106 - Controlled Substance Theft or Loss Report DEA Form 41 - Controlled Substance Destruction Report Counseling Log - Central Service Pharmacies Counseling Refusal Log - Non-Central Service Pharmacies Off-Site Remote Automated Distribution Pharmacy Service Application Power of Attorney Form for DEA Order Forms Variance Request Form - For New Requests Variance Renewal Form - For Renewal Requests Policy Review Request Cover Sheet - For Variance and Policy Review Committee Consideration License Closure Notification - In-State Pharmacy License Closure Notification - Out-of-State Pharmacy Requirements for a Valid Prescription in Minnesota Facility Name Change Form Pharmacy License Category Change Notification Pharmacists-in-Charge MN Resident: For pharmacists that are in the state of Minnesota. Guidelines for Pharmacists-In-Charge - Instructions for new, temporary, departing, and returning pharmacists-in-charge. Certificate of Professional Responsibility - Pharmacist-In-Charge (PIC) Form Temporary Pharmacist-In-Charge Responsibility Existing Variance Form for a Successor Pharmacist-In-Charge MN Resident Pharmacy: The following forms are to be completed and retained in the pharmacy's records and *not sent to the Board of Pharmacy. Power of Attorney for DEA Form 222 and Electronic Orders Pharmacy Technician Policy Community Pharmacy Practice - Pharmacist-In-Charge (PIC) Responsibility Survey Hospital Pharmacy Practice - Pharmacist-In-Charge Responsibility Survey For pharmacists not in the state of Minnesota, complete the following form and return it to the MN Board of Pharmacy within ten days* of your Pharmacist-In-Charge change. Non-Resident Pharmacy Certificate of Professional Responsibility - Pharmacist-In-Charge (PIC) Form Pharmacy License Renewal Documentation Forms: Non-Resident Pharmacies - Pharmacist Employees Non-Resident Pharmacies - Technician Employees for Limited or Central Service Pharmacy License Category Change Notification Non-resident Certificate of Responsibility - Pharmacist-in-Charge change form In-State Certificate of Responsibility - Pharmacist-in-Charge change form Officer Reporting Form List of Shareholders Form
Facilities - Manufacturers, Medical Gas Distributors, Third-Party Logistics Providers, & Wholesalers
License Closure Notification In-State and Out-State Facilities Facility License Category Change Notification Officer Reporting Form Payments to Practitioners Reporting Spreadsheet Facility Name Change Form Facility Manager or Designated Representative Change Affidavit License Renewal Documentation Forms: Facility Manager or Designated Representative Change Affidavit Facility Officer Reporting Form Facility Renewal - Category Change Form Facility Shareholder-Member-Partner Reporting Form Utilized CMOs, 3PLs, & Wholesalers Reporting Form
PMP Account Registration Exemption Form for Pharmacists
Affirmation of Exemption from Mandatory Registration of PMP Account - For Pharmacists who feel they are exempt from creating a Minnesota PMP account.
Americans With Disabilities Act (ADA) Information
ADA Notice to the Public Reasonable Accommodations Form
Miscellaneous
License Verification Request Form Foreign Pharmacy School Graduate Variance Request Open Appointments Application for Service on State Agency Variance request to retake the MPJE Variance request to retake the NAPLEX Controlled Substance Destruction: The following forms are to be completed and retained in the facility's records and *not sent to the Board of Pharmacy*. Form for LTCF Form for Supervised Living Facility/Home Care