CHANGE OF INFORMATION FORM
Please use the form below to notify
the Board within 30 days of changes in the following pharmacist information:
1.
Name
(must include documentation e.g., copy of marriage certificate, change of name
certificate, etc.);
2.
Address;
3.
Place
of Employment
4.
Telephone
number; and/or
5.
Other
pertinent information
The Board requires this change of
information to be reported in order to insure that the pharmacist licensee will
continue to receive relevant Board information, and that his/her license
renewal information will be processed timely.
Failure to provide the Board with certain up-to-date and accurate
information may constitute grounds for action under HO 12-313(b)(1), (6), (7) and/or (24), Annotated Code of Maryland.
PLEASE COMPLETE THE ENTIRE FORM
Effective
Date of Change:
|
PHARMACIST
NAME:
LICENSE NUMBER: |
|
PREVIOUS
NAME: ( Mail Legal Documentation to the Board with this form) |
|
PREVIOUS
ADDRESS: |
|
PREVIOUS
CITY/STATE/ZIP:
|
|
NEW
ADDRESS: |
|
NEW
CITY/STATE/ZIP: COUNTY:
TELEPHONE: |
|
Email Address: |
|
Do you want a new license
printed? YES NO If Yes, Include $30
Duplicate License Fee |
|
EMPLOYER NAME: PERMIT NUMBER: |
|
EMPLOYER
ADDRESS: |
|
EMPLOYER
CITY/STATE/ZIP COUNTY: TELEPHONE: |
|
FULL
TIME PART TIME UNEMPLOYED RETIRED OTHER |
Select One
|
01
PRIVATE SECTOR - PROFIT |
03
FEDERAL GOV’T - MILITARY |
05
STATE GOV’T |
07
SELF EMPLOYED |
|
02
PRIVATE SECTOR – NON PROFIT |
04
FEDERAL GOV’T – NON MILITARY |
06
LOCAL GOV’T |
08
OTHER: |
Select up
to Three
|
H 01 HOSPTIAL |
08 PRACTITIONER’S OFFICE-EMPLOYEE |
15 WHOLESALE ESTABLISHMENT |
21 FEDERAL GOV’T –NON MILITARY |
|
02 LONG TERM CARE |
09 INFUSION |
16 SCHOOL SYSTEM |
22 FEDERAL GOV’T-MILITARY |
|
03 NUCLEAR |
10 REHABILITATION AGENCY/CLINIC |
17 UNIV OR COLLEGE-ADMIN |
23 OTHER ( employ in field of
license) |
|
04 CLINIC |
11 HOME HEALTH |
18 UNIV OR COLLEGE- TEACHING |
24 OTHER (outside field of
license) |
|
05 GROUP PLAN/HMO |
12 SATELLITE |
19 UNIVOR COLLEGE – CLINICAL |
25 INTERNET |
|
06 PRACTITIONER’S OFFICE-SELF |
13MANUFACTURER/INDUSTRY |
20 UNIV OR COLLEGE.- RESEARCH |
|
|
07 PRACTITIONER’S
OFFICE-PARTNERSHIP |
14 RETAIL ESTABLISHMENT |
Mail, Fax
or eMail this form to:
Maryland
Board of Pharmacy
4201 Patterson Avenue
Baltimore, Maryland 21215
(410)764-2485 Telephone
(410) 358-6207 Fax
Email Address: MDBOP@DHMH.STATE.MD.US