Free 01572.FH11 - Indiana

INDIANA BOARD OF PHARMACY CHANGE OF QUALIFYING PHARMACIST
State Form 1572 (R3 / 2-06)

Pharmacy permit identification number (as it appears on permit) Name of proposed qualifying pharmacist Pharmacy telephone number RPh license number

INSTRUCTIONS:

Complete, sign and return along with the original pharmacy permit (maintaining a copy of permit for your records) to the: Indiana Board of Pharmacy Professional Licensing Agency 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2067 E-mail: [email protected] www.pla.IN.gov

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I hereby swear or affirm under the penalties of perjury that I am a duly licensed pharmacist in the State of Indiana, and by the execution of this document accept responsibility for the lawful conduct of said pharmacy, and I will notify the Indiana Board of Pharmacy not later than the effective date of my separation from such duties.
Signature of qualifying pharmacist Date signed (month, day, year)

Name and address of pharmacy (If information typed is not as it appears on pharmacy permit please correct)

Note: A pharmacist may qualify only one Indiana permit.