Arizona State Board of Pharmacy
PO Box 18520
Permit No. Fee Check # Receipt #
Non-Resident Relocation Application
The Arizona State Board of Pharmacy charges $10.00 for the reissuance of a permit after a relocation. If your facility is relocating
within the same state, please complete this form and mail it to the address above with a $10.00 check or money order and a copy of
your updated home state permit. If your facility is moving to another state, please complete and submit the appropriate new permit
application.
1. Business Name (as it appears on permit):
2. Permit No. Date of Relocation:
3. A
ddress (as it appears on permit)
Street:
City: State: Zip:
4. N
ew Address
Street:
City: State: Zip:
Phone: Email:
5. M
ailing Address (if different)
Street:
City: State: Zip:
A
dditional Changes
6. P
harmacist-in-Charge or Designated Representative
Name and Home State License No. of PIC:
Or
Name of Designated Representative:
Signature: Date:
