Applications and
Forms
*All of these files are in .pdf format.
If you haven't already downloaded Adobe Reader® on your computer to
open up .pdf documents, please visit the Adobe
Acrobat® site.
You can now complete applications online, then print
and mail in with the necessary requirements.
A-F
Ambulance/Emergency Medical Service Application (8k) (also
for change location and ownership)
Analytical Labratory Application (8k) K.A.R. 68-20-9;
68-20-10 (also
for change in location and ownership)
Complaint Form (8k)
Cancer Drug Repository Donation, Transfer & Destruction Record
Cancer Drug Repository Notice of Participation or Withdrawal Form
Cancer Drug Repository Patient Consent Form
Distributor of Prescription Drugs and/or Controlled Substances(12k)
& Letter
Concerning the Application K.S.A.
65-1645; 65-1655 K.A.R.
68- 14-1; 68-14-2; 68-14-3;
68-14-4; 68-14-5; 68-14-6;
68-14-7; 68-14-8 (also
for change in location and ownership)
Duplicate Wall Certificate Application (FOR PHARMACISTS
ONLY) (4k)
Duplicate Pocket Card
Application
Durable
Medical Equipment & Devices &
Letter Concerning the Application
G-L
Health Department and Private Not-For-Profit Family Planning Clinic (8k)
K.S.A. 65-1648 K.A.R. 68-7-18
(also for change in PIC, location,
and ownership)
Indigent Care Clinic (also
for change in PIC, location, and ownership)
Institutional Drug Room Registration Application (8k) K.S.A. 65-1626(o)(1);
65-1629; 65-1637a; 65-1643
( also for change
in PIC, location, and ownership)
Internship Affidavit (8k)
Internship Affidavit page 2 (8k)
Intern Application
M-Q
Nonprescription
Drug Distributor/Wholesaler Registration Application(12k) &
Letter
Concerning the Application K.A.R.
68-15-1; 68-15-2; 68-15-4
(also for change in location and ownership)
NonResident Pharmacy Registration Application (16k) K.S.A.
65-1657 K.A.R. 68-7-12a (also
for change in PIC, location, and ownership)
Open Records Request Form (To
view available disciplinary actions, go to the disciplinary
actions page.)
Pharmacist Licensure Application
(To obtain
the registration form for the MPJE, go to the NABP
website.)
Pharmacy Registration Application --Pharmacies in Kansas--(16k)
K.S.A. 65-1626(r) K.A.R. 68-1-2a;
68-1-8; 68-7-13; 68-2-9;
68-2- 10 (also for change in PIC, location, and ownership)
Manufacturer Registration Application (12k) (also
for change in location and ownership)
R-Z
Research and Teaching Institution Application (12k) (also
for change in location and ownership)
Retail Dealer Application (8k) (also
for change in location and ownership)
Retail Dealer Self Inspection Form
Risk Management Complaint Form (For Medical Care Facilities Only)
Sample Distribution Permit Application (4k)
Technicians Listing (8k)
Technicians Application and
Instructions
DEA
106 Form--Theft of Loss of Controlled Substances