Pharmacist License

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Demographics

* Last Name * First Name Middle Name Maiden Name
* Address 1 Lot/Apt #
* City * State * Zip * County
* Phone # * SSN # * Date of Birth Cell Phone #
* Email * Controlled Substance * Sex * Are you a United States Citizen?
CPE Monitor #

Regulatory Questions

1. Have you been arrested of a felony or misdemeanor, excluding minor traffic violations?


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Affirm pay and submit

I understand that I must comply with the provisions of the Alabama Practice Act, Rules of the Board and all other applicable statues and rules.
I affirm that all information provided herein is true and correct and I recognize that providing false information may result in disciplinary action

Date : 03/25/2017

(Board of Pharmacy charge will appear as "ALA ST BOARD OF PHARM" and convenience fee will appear as "Just E-Pay LLC" on your statement.)

*Amount Due : *Transaction Fee : *Total :
* Person's Name on Card: *Select Debit or Credit : *Card Type :
*Card # : *Expiration Date :
* Security Code :
(Board of Pharmacy charge will appear as "ALA ST BOARD OF PHARM" and convenience fee will appear as "Just E-Pay LLC" on your statement.)
 

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