License Application Forms
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.
All applicants for licensure must complete this form and submit it with the $339 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.
- Address/Name Change Form - Optional ( 20 KB)
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.
- 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 an Internship in Pharmacy ( 25 KB)
- 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. A separate Form 4 is required 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 4B - Certification of Completion of Pharmacy Practice Residency Competencies (pharm4b.pdf; 14K; 3 pages)
This form must be submitted directly by the residency program director.
This form is required for applicants seeking licensure without having taken and passed the Part III Written and Practical (Compounding) examination. This alternate pathway is described in Regulations of the Commissioner of Education, section 63.3 and applies only to those candidates for licensure who have gained the required competencies within a formal, approved pharmacy practice residency.
Applicants who have been unsuccessful on a previous Part III examination CANNOT use this alternate pathway to licensure; they must retake and pass Part III.
- Section I: Complete this section of the form before forwarding all three pages of this form to the residency program director and ask that they complete Section II.
- Section II: Measurement standards (see sample provided on page 3) as well as detailed information on measurement standards utilized for assessment of competencies must be submitted by the pharmacist residency program director along with this form.
The residency program director must submit this form as well as any other required information directly to the Office of the Professions at the address at the end of this form. This form will not be accepted if submitted by the applicant.
- 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 10 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).