OUTGOING CHANGE OF PHARMACIST-IN-CHARGE

This is for the outgoing PIC. You must report a change in PIC to the Board within 15 days.

Retail Pharmacy Registration # (Required if applicable)

Please enter the 7 digit license number
Institutional Pharmacy Registration # (Required if applicable)

Please enter the 7 digit license number
Retail/Institutional Pharmacy Name *
Pharmacy Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Pharmacy Phone * - ### - ### ####
Name of person completing this form * First Last
Name of Outgoing PIC * First Last
RPH License Number *
Effective Date of PIC Change (Last day as PIC) * / MM / DD YYYY
Email *
PIC, PLEASE CHECK ALL THAT APPLY
Is this a change in your employment location?
Yes No
If "Yes", are you the PIC at this new location? (If yes, you must also complete the Incoming PIC Online Change In Pic Form)
Yes No
New Employer Name
New Employer Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Employer Phone - ### - ### ####
New Employment Effective Date / MM / DD YYYY