Virginia Board of Pharmacy
Applications & Forms
Address of record
Section 54.1-2400.02.B of the Code of Virginia requires the Department of Health Professions (DHP) to collect an official address of record from each health professional to be used by DHP for agency purposes. The Code also requires DHP to provide an opportunity for a health professional to provide a second address for the purpose of public dissemination. If there is no second (public) address provided, the official address of record will be used as the public address for the purpose of public dissemination. This is applicable to all pharmacists, pharmacy interns, and pharmacy technicians. If the individual would prefer that his/her address of record remain confidential, then an alternative public address must be provided to DHP. (Note: the License Lookup feature on the DHP public website does not contain the full address. However, public addresses are available by contacting Virginia Interactive Premium Service or the Board.) An individual is not required to submit a place of residence for either the official address of record or the public address. A post office box or a practice location is acceptable. This is not true for facilities licensed by the Board of Pharmacy. The address of record for facilities must be the actual physical location of the facility.
Changes to either address may be made at the time of renewal or at any time by written notification to the Board. Changes to the address of record may also be made at any time by accessing your licensure information through the online system. Any change that is made to one of the addresses does not automatically update the other address. Address information should be kept current for the address of record and the public address (if different from the address of record) at all times.
Facilities licensed by the Board may only make changes to their address by filing an application with the Board prior to any change, and such change typically requires an inspection and approval of the new location.
The below documents are in Microsoft Word format. If you do not have Microsoft Word, you can get the Microsoft® Word Viewer 97/2000 to view and print documents.
Forms and Applications for Pharmacists
Guidance Document 110-2: Information for Applicants for a License as a Pharmacist - September 2009
Applicants for Pharmacist License by Examination, to include graduates of foreign schools of pharmacy, may now begin the application process by submitting the application fee online. Click here to begin the online application process.
Application for Pharmacist License by Examination
Guidance Document 110-17: Instructions for graduates of foreign schools of pharmacy - revised March 2010
Pharmacy Intern Application for Graduate of Foreign School of Pharmacy
Affidavit of Practical Experience as a Pharmacy Intern
Application for Reinstatement of Registration as a Pharmacy Intern
Instructions and Application to Reinstate or Reactivate a Pharmacist License
Forms for Pharmacies (In-State)
Pharmacy Closing Notification Form
Registration For A Pharmacy To Be A Collection Site For Donated Drugs
Forms for Other Facilities (In-State)
Medical Equipment Supplier Permit Application
Restricted Manufacturer Permit Application (for OTC drugs or transfilling medical oxygen)
Non-Restricted Manufacturer Permit Application
Wholesale Distributor License Application
Limited-Use Wholesale Distributor License Application
Forms for Facilities (Out-of-State)
Non-Resident Pharmacy Registration Application
Non-Resident Wholesale Distributor Registration Application
Medical Equipment Supplier Permit Application
Limited-Use
Wholesale Distributor License Application
Forms for Physicians
Application for a License for a Practitioner of the Healing Arts to Sell Controlled Substances
Permitted Physician Application
Forms Relating to Controlled Substances Registration
DEA Forms
Information regarding the filing of a Theft/Loss Report - DEA Form 106
Click here to link to DEA's website to obtain a copy of Form 106 - Theft/Loss Report
Application Forms regarding Pharmacy Technicians and Pharmacy Technician Training Programs
Applicants for Pharmacy Technician Registration may now begin the application process by submitting the application fee online. Click here to begin the online application process.
Instructions and Application for Registration as a Pharmacy Technician
Instructions and Application to Reinstate a Pharmacy Technician Registration
Affidavit by Free Clinic Director for Limited-Use Pharmacy Technician
Application for Approval of a Pharmacy Technician Training Program
Miscellaneous
Application for Approval of an Innovative (Pilot) Program
Application for Approval of ACPE Pharmacy School Course(s) for Continuing Education Credit
Application for Approval of Repackaging Training Program
Volunteer Practice Forms
Volunteer Practice Sponsor Form
Application for Registration for Volunteer Practice
Monitoring for Board Orders
Important Information About Your Board of Pharmacy Order
Self Report – Pharmacist or Pharmacy Technician
Performance Evaluation Form – Pharmacist or Pharmacy Technician