Microsoft Word - Pharmacist_Reinstatement_Application final rev 01282022

Revised 01/28/2022

PHARMACIST LICENSE APPLICATION

INSTRUCTIONS – REINSTATEMENT

 This application must be completed by for pharmacists who want to reinstate an expired

Maryland pharmacist license in accordance with the Md. Code Ann., Health Occ. §12-310 and

COMAR 10.34.13.

 To ensure accurate information from NABP and the Board, please indicate your E-Profile

number on the licensure application.

 Submit the completed application with all attachments and a check or money order made payable

to the Maryland Board of Pharmacy for the correct amount to:

Maryland Board of Pharmacy, P.O. Box 1991, Baltimore, Maryland 21203-1991

 Incomplete checks or money orders will be returned

 Applications sent overnight or through priority mail must be sent to:

Wells Fargo Bank, Attn: State of Maryland Board of Pharmacy, Lockbox 111991

401 Market Street, Philadelphia, PA 19106

 No applications with money orders or checks can be mailed to the office.

 Submit required CEs. A total of 30 Continuing Education Credit Hours (CEs), obtained within

the last two years, are required to be submitted at the time you apply for reinstatement. Two (2)

CEs must be live, one (1) CE must be on medication errors. A CE is considered “live” if it offers

the ability for the participant to have real-time interaction with the presenter, including programs

approved by the Accreditation Council for Pharmacy Education (ACPE) that are designated by

the letter “L” in the course identification number.

 To view and track continuing professional education credits from ACPE-accredited providers, all

pharmacist should obtain a National Association of Boards of Pharmacy (NABP) e-Profile

identification number. To view and track these credits, you must first set up an NABP e-Profile,

obtain your NABP e-profile ID, and register for CPE Monitor. You can obtain more information on

the NABP website at https://store.nabp.net/OA_HTML/xxnabpibeGblLogin.jsp. (Note: non-ACPE-

accredited courses must be approved by the Board, and are not retrievable from CPE Monitor.)

 Pharmacists reinstating within their first renewal period are not required to submit CEs if the

original license was obtained within one (1) year of graduation.

 CEs used to renew your Vaccine Certification can also be used to renew your license. If you are

renewing your Vaccine Certification, complete Attachment 2.

In addition to the above:

A. If applying within 2 years of expiration of your license, enclose check or money order for: $527.00

B. If applying more than 2 years after expiration of your license, enclose check or money order for:

$542.00

 Apply to take the MPJE with NABP online at (www.NABP.net.)

 After applying to NABP, you will receive an Authorization to Test (ATT). The ATT will be issued

only after you meet all of the application requirements and after payment to NABP.NABP will

send you an ATT number to use when scheduling the required examinations.

Revised 01/28/2022

 Examination results will be forwarded electronically to the Board within 2-3 business days after

the test is taken. Unofficial scores are posted on NABP’s web site, www.NABP.net.

C. If applying more than 5 years after expiration of your license and you have not been actively

engaged in the practice of pharmacy in another state, you must complete Attachment 1, Pharmacy

Experience Affidavit, in addition to the above.

 NOTE: The application fee is a non-refundable, administrative fee.

Your application will be valid for one year from the date received by the Board. If you have not

met criteria within one year, you must resubmit an application and the applicable fees. Fees paid

for applications that have expired will not be refunded or credited.

Revised 01/28/2022

APPLICATION FOR PHARMACIST LICENSURE

REINSTATEMENT

 Please print clearly or type in upper case letters only.

 Complete all application sections and sign. Incomplete forms will delay the issuance of your

license.

If applying

within 2 years

of expiration of license,

enclose check for:

If applying

more than 2 years

after expiration of

license, enclose check for:

☐Total Due: $527.00

☐Total Due: $542.00

NABP E

PROFILE #

1. IDENTIFICATION

☐

MALE

☐

FEMALE

First Name:

Middle / Maiden Name:

Last Name:

Application Date:

Street Address

City:

State:

Zip:

Home Phone:

Work Phone:

Cell Phone:

Social Security Number:

Date of Birth

Email Address:

License Number

Date

of Initial Licensure:

Initially Licensed in

Maryland by:

☐ EXAM ☐ RECIPROCITY

License Expiration Date:

Maryland Board of Pharmacy

4201 Patterson Avenue

Baltimore MD 21215-2299

Phone: 410-764-4755

Fax: 410-358-6207

www.dhmh.maryland.gov/pharmacy

Revised 01/28/2022

VETERANS AND SPOUSAL PREFERENCE

Are you an active service member of the spouse or an active service

member?

☐ YES ☐ NO

Are

you a veteran or the spouse of a veteran who was discharged from

active duty under a circumstance other than dishonorable within one (1)

year of filing this application?

☐ YES ☐ NO

EMPLOYER INFORMATION

List work experience for the past 2 years, including the name and address of each employer and the

period of service. Attach additional sheets if needed. If your license expired more than five years

ago and you have not been actively engaged in the practice of pharmacy in another state, you

must complete Attachment 1 – Pharmacy Experience Affidavit.

EMPLOYER NAME

DATES OF EMPLOYMENT

ADDRESS & TELEPHONE #

TRAINING ON ADMINISTRATION OF SELF

ADMINISTRED DRUGS

I attest that I have the

proper training on the Administration

of Self-Administered Drugs per COMAR 10.34.39

☐ YES ☐ NO ☐ N/A

If “YES”, do you have an active Certification in Basic

Cardiopulmonary Resuscitation?

☐ YES ☐ NO

If “YES”, provide expiration date:

LICENSURE HISTORY

Indicate licensure information about all current and previously held licenses to practice pharmacy. Attach

additional sheets if needed. Submit a written explanation of any license that is not in good

standing.

License Number &

State

Original License Issue

Date License Expiration Date

Name, Address &

Telephone Number of

Last Employer

Revised 01/28/2022

PERSONAL ATTESTATION QUESTIONS

Please read this section carefully and answer “Yes” or “No” to the following questions related to your

practice as a pharmacist. If you answer “Yes” to any question, please provide a detailed explanation

(attach additional pages if necessary) and attach supporting documents to explain your answer. Failure

to provide complete and correct information may result in delay, or denial, of your application for

registration

Has any state licensing or disciplinary board (including Maryland)

or any similar agency in the Armed Forces, denied your

application for a license, reinstatement or renewal, or taken any

formal disciplinary action against any registration or license held

by you? Such actions include, but are not limited to, reprimand,

suspension, or revocation

☐ YES ☐ NO

Has any state licensing or disciplinary board

(including Maryland)

or similar agency in the Armed Forces, filed any complaints or

charges against you or investigated you for any reason?

☐ YES ☐ NO

Have you surrendered or failed to renew a healthcare registration

or license in any state?

☐ YES ☐ NO

Have you ever withdrawn your application for a pharmacist’s

license or other health professional license?

☐ YES ☐ NO

Has your employment by any pharmacy, clinic, healthcare

practice, or wholesale drug distributor been terminated for

disciplinary reasons?

☐ YES ☐ NO

Have you committed a criminal act for which you pled guilty or

nolo contendere (see definition below), or for which you were

convicted or received probation before judgment?

☐ YES ☐ NO

Excluding minor traffic violations, are you currently under arrest

or released on bond, or are there any current or pending charges

against you in any court of law?

☐ YES ☐ NO

Have you committed an offense involving alcohol or

controlled

substances to which you pled guilty or nolo contendere, or for

which you were convicted or received probation before

judgment?

☐ YES ☐ NO

Do you have a physical or mental condition that may impair your

ability to practice pharmacy?

☐ YES ☐ NO

10.

Has your ability to practice pharmacy been affected by the use of

any type of drug or alcohol?

☐ YES ☐ NO

11.

Have you worked as a pharmacist in a Maryland pharmacy or a

non-resident Pharmacy serving Maryland residents since the

expiration date of your license?

☐ YES ☐ NO

** Nolo contendere- A plea in a criminal case which has a similar legal effect as pleading guilty.

The defendant does not admit or deny the charges, but a fine or sentence may be imposed

based on this plea.

I affirm that the information I have given in answer to these questions is true and correct to the

best of my knowledge and belief. I have read the Maryland Pharmacy Act, Section 12-101 et.

seq., Health Occupations Article, Annotated Code of Maryland, and Board regulations, COMAR

10.34.01 et seq., and if licensed, I agree to practice pharmacy in accordance with laws of

Maryland.

Signature:

Date:

Revised 01/28/2022

LIST OF DESIGNEE

If applicable, list

the names of person and/or entity that you authorize the Board to

release information about your application:

Name of Organization

Name of Person

Title

CONTINUING EDUCATION RECORD FORM

A total of

30 Continuing Education Credit Hours (CEs)

, obtained within the last two years, are

required to be submitted at the time you apply for reinstatement. Provide the CE information in

the chart below.

Two (2) CEs must be live, one (1) CE must be on medication errors. CE is considered “live” if it

offers the ability for the participant to have real-time interaction with the presenter, including

programs approved by the Accreditation Council for Pharmacy Education (ACPE) that are

designated by the letter “L” in the course identification number.

Pharmacists reinstating within their first renewal period

are not

required to submit CEs

if the

original license was obtained within one (1) year of graduation.

Would you like to renew your Maryland Vaccination certification? ☐ Yes ☐ No

CEs used to renew your Vaccine Certification can also be used to renew your license.

If you are

renewing your Vaccine Certification, complete Attachment 2.

Please add additional pages if you require additional space to enter CEs.

Use the following codes: 1. Live CE; 2. Medication Errors; 3. Vaccine

NAME

LICENSE #

NABP e

PROFILE #

CE Program Name Provider

Date Hours

Taken

ACPE/Board

Approval Number

Code

# of

Hours

TOTAL # OF HOURS:

Revised 01/28/2022

I affirm under penalty of perjury that the information I have given on this continuing education record is

true and correct to the best of my knowledge and belief.

Signature:

Date:

Would you like to receive license renewal notification via email?

☐ YES ☐ NO

Would you like to be an emergency preparedness volunteer?

☐ YES ☐ NO

________________________________

, do solemnly swear or affirm under the penalties of

perjury that I have personally completed this application, that the foregoing information is true,

correct and complete to the best of my knowledge and belief, and that I understand that any

misrepresentation may constitute grounds for revoking this license

Applicant’s

Signature:

Date:

VOLUNTARY EQUAL OPPORTUNITY INFORMATION

To further its commitment to equal opportunity, the Board of Pharmacy requests applicants to

VOLUNTARILY provide the following information. This information will be used for statistical purposes

only by authorized personnel.

RACE:

Are you of Hispanic or Latino origin?

☐ YES ☐ NO

If you are not of Hispanic or Latino origin, select one or more of the following racial categories:

American Indian or Alaska Native (A person having origins in any of the

original peoples of North or South America, including Central America, and

who maintains tribal affiliations or community attachment.)

☐

Asian (A

person having origins in any of the original peoples of the Far East,

Southeast Asia, or the India subcontinent, including, for example, Cambodia,

China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands,

Thailand, and Vietnam.)

☐

Blac

k or African American (A person having origins in any of the black racial

groups of Africa.)

☐

Native Hawaiian or other Pacific Islander (A person having origins in the

original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.)

☐

White (A person having origins in any of the original peoples of Europe, the

Middle East, or North Africa.)

☐

Revised 01/28/2022

APPLICATION FOR PHARMACIST LICENSURE

NEW OR FOREIGN GRADUATES

ATTACHMENT 1

PHARMACY EXPERIENCE AFFIDAVIT

(Please Fill In All Blank Spaces)

I, the undersigned, hereby certify that I am a licensed Pharmacist in the State of ___________,

License Number: ________________,

and that ___________________ received practical pharmacy experience as follows:

(Applicant Name)

HOURS OF EXPERIENCE

From

# of Weeks

Hours Per Week

Hours Earned

TOTAL HOURS reported on the form:

I,______________________________,

(Supervising Pharmacist)

do solemnly swear or affirm, under the penalties of perjury, that I have personally completed this form to

the best of my knowledge and belief, that I understand that perjury on this form will constitute grounds for

revoking any license issued which uses this form as a supporting document.

State of _______________________; County or City of _______________________

SIGNATURE:

PHARMACY:

ADDRESS:

DATE:

IMPORTANT NOTICE

: This affidavit must be notarized and submitted with application where

appropriate.

Revised 01/28/2022

APPLICATION FOR PHARMACIST LICENSURE

REINSTATEMENT

ATTACHMENT 2

VACCINE CERTIFICATION RENEWAL FORM

Please print clearly in ink or type in upper case letters only.

NAME

DATE

LICENSE NUMBER

CPR Certification

A Current CPR Certification card is required. Please attach a copy of the CPR card (front and back) to

this application. The certification must be obtained through in-person classroom instruction.

Copy of CPR Card attached to this application?

☐ YES ☐ NO

Continuing Education Credit Hours (CEs)

The four (4) hours needed to renew your Vaccine Certification may count towards the 30 total CEs

required to renew your license.

CE Topic

CE Program

Name ACPE Number # of Credits Date

I affirm under penalty or

perjury, that the information I have given on this record is true and

correct to the best of my knowledge and belief.

Applicant’s

Signature:

Date: