RxCircle: We focus on improve the quality of life, patient care, and well being

License Application Forms

Instructions for completing and submitting the forms required for licensure appear below. You may also need to submit additional information (for example, examination scores). Please refer to the license requirements link on the left for complete information regarding all requirements you must meet.

Note: All forms are in Adobe Portable Document Format (PDF). To view or print these documents, you will need to have the free Adobe Reader installed on your computer. Download times and print quality will depend on your connection speed and printer.

Adobe Reader

Form 1 - Application for Licensure & First Registration (pharm1.pdf; 23K; 4 pages)

All applicants for licensure must complete this form and submit it with the $270 licensure and registration fee directly to the Office of the Professions at the mailing address at the end of Form 1. Make checks payable to the New York State Education Department. NOTE: Your cancelled check is your receipt. You must answer all questions and provide all information requested unless otherwise indicated. Failure to complete all required parts of the application will delay its review. Your signature on Form 1 must be notarized by a Notary Public. Upon receipt of your completed application, we will send you an acknowledgement letter.

Address/Name Change Form - Optional (anchange.pdf; 16K; 2 pages)

You are required to notify us within 30 days of any name or address changes. Please read the instructions and complete the appropriate sections of this form.

Form 1LL - Application for a Three-Year Limited License (pharm1ll.pdf; 18K; 2 pages)

Applicants who have met all other requirements for licensure as a pharmacist except U.S. citizenship or permanent resident alien status, can apply for a three-year limited license by completing Form 1LL and submitting an additional fee of $270.

You must also file a complete New York State application for a license as a pharmacist (Form 1) and submit that fee and all required documentation.

An applicant for a three-year limited license must pay a total fee of $540.

The authority of the Board of Regents to grant three-year limited licenses (or extensions of those licenses) expires September 30, 2006.

Form 2 - Certification of Professional Education (pharm2.pdf; 21K; 3 pages)

This form must be submitted directly by the educational institution.

Section I: Complete this section of the form before sending it to your school.

Section II: If you graduated from a pharmacy program that was accredited by ACPE, the registrar must complete this section. Applicants who are expected to graduate from these programs should forward this form to their academic institution for completion of Section II. The registrar must return the completed form directly to the New York State Education Department.

Note: All pharmacy schools in the United States are currently accredited.

Part B is for all other programs. Applicants who are graduates of these programs should forward this form to their academic institution for completion of Section II. The Registrar must return the completed form directly to the New York State Education Department along with an official transcript.

Form 4 - Certification of Completion of an Internship in Pharmacy (pharm4.pdf; 25K; 4 pages)

This form is not required for PharmD graduates from ACPE or CCAPP accredited programs.

Use Form 4 to certify the completion of the required internship, which can only be performed under an authorized permit. Attach the experience log with Form 4 only if the hours are different each week. A separate Form 4 is required for each time period, for each pharmacy, and for each preceptor and should be completed, signed by both intern and preceptor, and returned to the Department at the address on the form. Pharmacy payroll records may be requested during periodic routine audits.

The Department must receive Form 4 and approve the internship certification before you will be admitted to Parts II and III of the licensing examination series. Incomplete forms or failure to comply with the internship requirement will prevent your admission to the exam.

Section I: Please complete this section of the form before submitting it to your preceptor pharmacist.

Section II: Your preceptor pharmacist must complete this section.

Section III: You and your preceptor pharmacist must sign in this section, affirming that the statements in Section I and Section II are true.

Section IV: If you are seeking credit for an internship completed in another state, submit this form to the authorized representative of that State's Board of Pharmacy for verification.

Internship Submission Deadlines

If you would like to take the exam in:	Your complete application must be postmarked by:
January	November 1 of the previous year
June	April 1 of the same year

Form 5 - Application for a Limited (Intern) Permit (pharm5.pdf; 27K; 4 pages)

You must obtain an intern permit before engaging in the supervised practice of pharmacy in New York. Answer all questions on Form 5 and send it with your fee of $70 to the New York State Education Department. Be sure to sign item 12 and have your signature notarized by a notary public.

If you are a student in an accredited pharmacy program, the school must certify that you have completed at least the third year of a five- or six-year curriculum by completing the back of the Form 5.
If you are a graduate from a non-accredited program, do not submit Form 5 until after you have passed NAPLEX (Part I).