Forms

The Board will only accept current TYPED versions of Board of Pharmacy forms. Old forms or handwritten forms will be returned (with payment) directly to the sender without processing. To ensure the most recent version, check the "Revised" date in the bottom right corner of each form.

On this page you'll find ALL Board of Pharmacy forms that are currently available online. Links on other web pages may direct you to these forms. Use the descriptions to find the right forms, which are available in pdf format and able to be electronically filled and signed online for submission to the Board office. Make sure you have included all fees and supporting documentation.

Applications for Pharmacists, Interns, and Technicians
Facility and Business Applications
Supplemental Forms
Continuing Education - Request for Approval
Miscellaneous Forms

Form #	Form Name	Revision Date
LA-01R	LA-01R Pharmacist by Reciprocity-Transfer	05/2021
LA-01E	Pharmacist by Exam (NOT Transfer or Reciprocity)	09/2023
LA-03	Pharmacy Intern	09/2023
LA-14	Pharmacy Technician	09/2023
LA-40	Online Account Update Change in Name or Contact Info	07/2018
LA-50	Online Account Update Change in Employment	07/2018
LA-55	Change in Pharmacist License Status	07/2018
LA-60	Pharmacist - Reinstatement	09/2022
LA-65	Pharmacist - Reinstatement after Revocation	09/2022
LA-70	Technician - Reinstatement after Revocation	09/2023
LA-75	Technician Certification Extension Request	11/2022
LA-80	Duplicate Pocket Card	07/2018
LA-85	Duplicate Pharmacist Wall License	07/2018
LA-100	Pharmacist Original Wall License	07/2018

Form #	Form Name	Revision Date
BA-02	Pharmacy (Resident)	06/2023
BA-04	Manufacturer	09/2022
BA-05	Distributor (cs, prescription drugs, oxygen, & devices)	09/2022
BA-06	Nonprescription Drug Distributor	12/2022
BA-07	Research/Teaching Institution	05/2022
BA-08	Analytical Lab	05/2022
BA-09	Ambulance or EMS (in state)	03/2022
BA-10	Retail Dealer	08/2023
BA-11	Health Department or Clinic (in state)	06/2023
BA-12	Institutional Drug Room (in state)	06/2023
BA-15	Sample Drug Distributor	03/2022
BA-16	Durable Medical Equipment	03/2022
BA-20	Outsourcing Facility	06/2023
BA-21	Automated Drug Delivery System in LTCF	06/2023
BA-22	Non-Resident Pharmacy	01/2022
BA-23	Third-party Logistics Provider	12/2022
BA-25	Nonprescription Third-Party Logistics Provider	12/2022
BA-50	Change in PIC/PIC Resignation	12/2023
BA-55	Change in Designated Representative (or other)	03/2020
BA-60	BA-60 Facility Closure Notice	09/2022

S-100	Background Check	Waiver for KBI/FBI background check and instructions for Fingerprint Card
S-150	Personal History	For individual applications with offense, disciplinary or criminal history
S-200	Continuing Education	For pharmacist applications for reinstatement
S-300	Disciplinary History	For facilities reporting disciplinary history
S-310	Partnership Ownership	For facilities owned by a partnership or limited partnership
S-320	LLC Ownership	For facilities owned by an LLC
S-330	Corporate Ownership	For facilities owned by a public, private, or non-profit corporation
S-340	$25,000 Surety Bond Form	$25,000 surety bond form for wholesale distributors
S-345	$100,000 Surety Bond Form	$100,000 surety bond form for wholesale distributors
S-350	Non-Resident Supplement	For non-resident pharmacies, distributors, nonprescription distributors, and DME.
S-400	Intern Experience Hours	Log and Preceptor Certification for pharmacy intern experience hours
S-500	Kansas Hospital Electronic Supervision Form	For hospitals receiving remote supervision
K-10	K-10 Notice of Exemption from Reporting	For pharmacies that do not dispense controlled substances
N-100	Automated Drug Delivery System Notice: Installation or Removal	This form is for a pharmacy, located and registered in Kansas, who will have an automated drug delivery system located in that pharmacy, institutional drug room, or medical care facility. For LTCF Automation: See BA-21
N-400	N-400 Participation Form-Donating Entity	This form is for medical care facilities, mail service pharmacies and adult care homes intending to participate in the Utilization of Unused Medications program by donating medications.
N-450	N-450 Participation Form-Clinics & Qualifying Centers	This form is for clinics and qualifying centers intending to participate in the Utilization of Unused Medications program by accepting medications.

E-100	Request CE Approval - Provider
E-200	Request CE Approval - Individual

C-100	Complaint Form
C-200	Transfer of Controlled Substances
C-500	CQI Meeting Report
C-600	Incident Report Form
C-700	ePrescribing Waiver Request Form
C-800	Open Records Request Form
C-900	Pharmacy Technician List
	Pilot Project Application
DEA 106	Theft or Loss of Controlled Substances Form