Fillable Arizona State Board of Pharmacy FOR AGENCY USE (Arizona)

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Arizona State Board of Pharmacy FOR AGENCY USE (Arizona)

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Country of origin: US
File type: PDF

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Arizona State Board of Pharmacy
Physical Address: 1616 W. Adams, Suite 120, Phoenix, AZ 85007
Mailing Address: P.O. Box 18520 Phoenix, AZ 85005
Phone: 602-771-ASBP (2727) Fax: 602-771-2749
www.pharmacy.az.gov
FOR AGENCY USE ONLY
ASBP Approval: Lic. / Permit No.: Fee: Receipt No.:
Receipt Date: Certificate Mailed: Check No.: Check Date:
5.8.17
CERTIFICATE REQUEST / REPLACEMENT
( All documents listed below $10.00 each; example: 2 relief certificates = $20.00)
Name:
Lic. / Permit No.:
Current white paper permit ( for Pharmacies, Non-Rx Retailers, Wholesalers, Medical Gases / DME & Manufacturers )
Quantity:
Current white paper license ( for Pharmacists, Interns & Technicians )
Quantity:
White paper relief certificate ( for Pharmacists, Interns & Technicians )
Quantity:
Parchment paper wall certificate * ( for Pharmacists, Interns & Technicians )
Quantity:
* Reason:
Lost Stolen Damaged Name Change ( attach documentation )
Total # of Certificates Desired @ $10.00 each =
If due to name change, please print new name as you would like it to appear:
Address ( Street and Number ):
City:
County:
State:
Zip Code:
Email:
Phone:
Fax:
Signature:
Date:
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Arizona State Board of Pharmacy FOR AGENCY USE (Arizona)

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Completed 20 July 2020

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