Pharmacist Licensure Renewal Form 2001 printable pdf download

The State Of New Hampshire

Board of Pharmacy

57 Regional Drive

Concord, NH 03301

2001 PHARMACIST LICENSURE RENEWAL FORM

Your license to practice pharmacy in NH expires December 31, 2000.

RENEWAL FEE: $75.

NH Lic. No. __________

Name:

Please Make Check Payable To:

_____________________________________________

NH BOARD OF PHARMACY

Mailing Address:

__________________________________________________

A $25. late filing fee must accompany any

City/State/Zip:

__________________________________________________

application postmarked later than 12/31/00.

Social Security #:

Date Of Birth:

Home Phone #:

__________________________

__________________

___________________________

Primary Employer:

Currently practicing pharmacy in New Hampshire?

___________________________________________________

Yes

Please list all states where you are presently licensed to practice pharmacy:

______________________________________________________

REPORT ON CONTINUING EDUCATION

COMPLETE THE FOLLOWING TWO STATEMENTS:

I have completed a total of ____________ hours of approved continuing pharmaceutical education during calendar year 2000 for

2001 licensure.

Of the total reported hours, I have completed ____________ hours in didactic (live) programming.

DO NOT SUBMIT CERTIFICATES OF CE PARTICIPATION WITH THIS APPLICATION.

Please read the following statements carefully and CHECK ONE box for each:

have

have not been convicted, fined, disciplined or had my license revoked for violation of pharmacy-related drug laws or regulations

in this or any other state.

am not

presently charged with any violations of pharmacy-related drug laws or regulations.

am not (to my knowledge) currently being investigated for possible violations of pharmacy-related drug laws or regulations.

have

have not

been convicted of a felony as defined under any state or federal law.

am not

presently charged with the commission of any such felony.

Under penalty of perjury, my signature below affirms that the answers and statements made on this application are true and

correct, to the best of my knowledge and belief.

Signature: ______________________________________________________________________

Date: ____________________________

THIS APPLICATION WILL NOT BE ACCEPTED WITHOUT A SIGNATURE AND DATE OF COMPLETION.

Pharmacist Licensure Renewal Form 2001

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