Fillable Pharmacist Emeritus Status (State of Ohio)

Fill Online, Printable, Fillable, Blank Pharmacist Emeritus Status (State of Ohio) Form

Use Fill to complete blank online STATE OF OHIO (OH) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Pharmacist Emeritus Status (State of Ohio)

On average this form takes 2 minutes to complete

The Pharmacist Emeritus Status (State of Ohio) form is 2 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 6 other fields

Country of origin: US
File type: PDF

U.S.A. forms for State of Ohio

BROWSE STATE OF OHIO (OH) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
77 South High Street, 17th Floor, Columbus, Ohio
43215
T: (614) 466.4143 |
F: (614) 752.4836 | contact@pharmacy.ohio.gov |
www.pharmacy.ohio.gov
Pharmacist Emeritus Status
Revised: 10/28/2021
Rule 4729:1-2-10 of the Ohio Administrative Code permits a pharmacist to place their license into
emeritus status. This rule is intended to permit a pharmacist who retires from the practice of
pharmacy to maintain their license as an emeritus pharmacist.
By placing a license into emeritus status, a pharmacist agrees to the following terms:
The pharmacist is no longer permitted to engage in the practice of pharmacy in this state.
Upon issuance of an emeritus designation, a license authorizing the person to practice
pharmacy shall be considered void and may only be renewed or reinstated in accordance
with the standard renewal or reinstatement process.
For a pharmacist to qualify for emeritus status, they must meet the following requirements:
1. Is currently or has been licensed to practice pharmacy in this state for at least ten years;
2. Is retired from the practice of pharmacy;
3. Is in good standing*;
4. Is at least sixty years old; and
5. Has applied for an emeritus designation using the form on the next page of this document.
*In good standing means a pharmacist to which all the following apply at the time of their
emeritus application: (a) Does not have a board order restricting the privilege of supervising
interns; (b) Has not been denied a license, registration or certificate by any public agency or
licensing agency; (c) Does not have a license, registration or certificate limited, suspended, or
revoked by any public agency or licensing agency.
IMPORTANT REMINDERS ABOUT EMERITUS STATUS:
The continuing education requirements of Chapter 4729:1-5 of the Administrative Code are
not applicable to an emeritus pharmacist.
An emeritus pharmacist shall not be subject to the licensure renewal requirements or
renewal fees.
An emeritus pharmacist is no longer permitted to engage in the practice of pharmacy.
There is no fee associated with the submission of this form.
Pharmacist Emeritus Request Form (Rev. 10/28/21)
This form must be submitted as a Submit Additional Documentation
request via eLicense
Ohio or may be emailed to: licensing@pharmacy.ohio.gov.
Part 1 – Emeritus Pharmacist Information
First Name
Last Name
Date of Birth (MM/DD/YYYY)
Ohio Pharmacist License No.
Part 2 – Attestation by Emeritus Applicant - To be completed by the emeritus applicant. Must
be manually signed in ink. Digital signatures will NOT be accepted.
I DECLARE UNDER PENALTIES OF FALSIFICATION AS SET FORTH IN CHAPTERS 2921. AND 4729.
OF THE OHIO REVISED CODE
THAT I MEET THE REQUIREMENTS SET FORTH IN RULE 4729:1-2-10
OF THE OHIO ADMINISTRATIVE CODE
AND HEREBY REQUEST MY PHARMACIST LICENSE BE
PLACED
INTO EMERITUS STATUS.
I FURTHER ACKNOWLEDGE THAT BY SUBMITTING THIS FORM
,
MY LICENSE WILL BE PLACED INTO
AN INACTIVE STATUS THAT WILL NOT PERMIT ME TO ENGAGE IN THE PRACTICE OF PHARMACY
PURSUANT TO
CHAPTER 4729. OF THE OHIO REVISED CODE AND THAT MY LICENSE MAY
ONLY BE
RENEWED/REINSTATED
IN ACCORDANCE WITH THE PROVISIONS SET FORTH IN CHAPTER
4729:1
-2 OF THE OHIO ADMINISTRATIVE CODE.
Signature of Applicant
Date Signed
Print or Type Name
This form must be submitted as a Submit Additional Documentation
request via eLicense
Ohio or may be emailed to: licensing@pharmacy.ohio.gov.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Pharmacist Emeritus Status (State of Ohio)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 30 October 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document