Fillable Pharmacist Application for Initial Approval to Administer Vaccines (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Pharmacist Application for Initial Approval to Administer Vaccines (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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The Pharmacist Application for Initial Approval to Administer Vaccines (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General) form is 2 pages long and contains:

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  • 0 check-boxes
  • 13 other fields

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File type: PDF

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
Board of Pharmacy
124 Halsey Street, 6th Floor, P.O. Box 45013
Newark, New Jersey 07101
(973) 504-6450
Pharmacist Application for Initial Approval to Administer Vaccines
Instructions
1. Complete,signandhavetheapplicationnotarized.
2. AttachacopyofyourimmunizationcoursecompletioncerticateasoutlinedinN.J.A.C.13:39-4.21(b)1i-xiii.
3. AttachacopyofyourcurrentcerticationinBasicLifeSupport(B.L.S.)orCardiacPulmonaryResuscitation(C.P.R.).
4. PleasereturnthisformtotheBoardofPharmacyattheaddressabove.
5. Incomplete applications will be returned, which will delay your approval.
Applicant’s Information
Please print CLEARLY.
Name:_____________________________________________________________________________________________

LastFirstMiddle
Licensenumber:_____________________________________
Mailingaddress:_____________________________________________________________________________________

StreetAddressCityStateZIPCode
Telephonenumber:___________________________
(includeareacode)
Pharmacy Practice Site/Primary Place of Employment
Name:_____________________________________________________________________________________________


PharmacyPermitnumber:_____________________________________
Address:___________________________________________________________________________________________

StreetAddressCityStateZIPCode
Telephonenumber:___________________________
(includeareacode)
Rev.4/11/17
AffidAvit with Acknowledgment
(Notarization required)
I, ___________________________________________ , in making this application to the Board for approval to administer
vaccines, certify that I am the applicant and swear and afrm that the statements made in this application, including
accompanying documents, are true, complete and correct. I understand that any false or misleading information in, or in
connection with, my application may be cause for denial of approval or to withhold renewal of or suspend or revoke a
license issued by the Board.
_____________________________________________
Signature of applicant
Sworn and subscribed to before me this _____________
day of _________________________ , ____________
Month Year
_____________________________________________
Name of Notary Public (please print)
_____________________________________________
Signature of Notary Public
Afx Seal Here
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Pharmacist Application for Initial Approval to Administer Vaccines (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 15 August 2020

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