:: Initial Applications ::

NEW PHARMACIST INSTRUCTIONS

For application information and instructions, please go to this link: https://doh.sd.gov/licensing-and-records/boards/pharmacy/licensing-requirements/pharmacists/

PHARMACIST INFORMATION

First Name

Middle Name

Last Name

Maiden Name

Mailing Address

Address1

Address2

Address3

Zip

City

State

County

Date of Birth

Social Security Number

Primary Phone Number

Alternate Phone Number

Gender

Male

Female

NABP e-profile #

EDUCATION

College Degree section below to be completed by New by NAPLEX exam, New by Score Transfer, Foreign Graduate, Reciprocating

Degree

Accredited College of Pharmacy Attended

Attended From

Attended to

Anticipated or actual date of graduation

College

PRACTICAL EXPERIENCE COMPLETED

Record all intern practical experience hrs in one entry for each pharmacy, provide overall date range FROM ______ TO______ with a total of all hours for each intern practical experience at each pharmacy.

Intern Registration Number

State Registered In

College Based Clinical Program

Yes

Was this for

IPPE

APPE

Are these intern practical experience hours?

Yes

Pharmacy Name

Pharmacy City

List Exact Dates(From/To)

Date From

Date To

Total Hours Worked

AUTHORIZATION TO ADMINISTER IMMUNIZATIONS

Will you be administering immunizations?

Yes

Attachments

A passport quality color photo of head or head/shoulder (2 ¼” x 3 ¼” in size).

Copy of a United States or state government issued photo ID (ex: driver’s license).

APPLICATION INPUT PREVIEW

AFFIRM AND SUBMIT

I the undersigned being duly sworn say that I am the person referred to in the foregoing application the photograph is an image of me and declare and affirm under the penalties of perjury that this application has been examined by me and to the best of my knowledge and belief is in all things true and correct.

E-Signature of the person filling out this renewal (Type in full name)

Date

License Fee

Select Debit or Credit

Card Type

Person’s Name on Card

Card #

Expiration Date (MM/YY)

Security code (3-digit number or 4-digit number if American Express/Amex)

All application fees are nonrefundable and nontransferable.