Pharmacy License Extension Form
Please fill out the form to apply for your pharmacy license extension.
Pharmacy Name
License Number
License Expiry Date
-
Month
-
Day
Year
Date
Applicant Full Name
First Name
Last Name
Applicant Contact Email
example@example.com
Applicant Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Upload Current License Document
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Reason for Extension Request
Submit
Should be Empty: