Arizona State Board of Pharmacy
PO Box 18520
Permit No. Fee Check # Receipt #
Resident Relocation/Remodel Application
Relocation - The Arizona State Board of Pharmacy charges $10.00 for the reissuance of a permit after a relocation. If
your facility is relocating within Arizona, please complete this form and mail it to the address above with a
$10.00 check or money order. Pharmacies, Manufacturers, Wholesalers and 3PLs, please send a copy of
the layout of the facility and lease or zoning statement. Gas Distributors, Gas Suppliers and DME, please
send a copy of your lease or zoning statement.
Remodel - Please complete this form and mail it to the above address with a copy of the new layout.
1. Business Name (as it appears on permit):
2. Permit No. Date of Relocation/Remodel:
3. Address (as it appears on permit)
Street:
City: State: Zip:
4. New Address
Street:
City: State: Zip:
Phone: Email:
5. Mailing Address (if different)
Street:
City: State: Zip:
Additional Changes
6. Pharmacist-in-Charge or Designated Representative
Name and Home State License No. of PIC:
Or
Name of Designated Representative:
Signature: Date:
