"Request for Approval of Temporary Pharmacist's License" - Nevada

Request for Approval of Temporary Pharmacist's License is a legal document that was released by the Nevada State Board of Pharmacy - a government authority operating within Nevada.

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Nevada State Board of Pharmacy
Request for Approval of Temporary Pharmacist's License
Fax: (775) 850-1444
***A temporary license can not be applied for usless you have submitted the Nevada
application for reciprocation.*** Only pharmacists reciprocating to Nevada are eligible
for a temporary license. You can submit the form with your application or fax to the
number above. A temporary license is only valid for 6 months and can not be extended.
A Nevada address is required.
Name:
Nevada Address:
City:
State: NV Zip:
Telephone:
E-mail:
Reason for Temporary License:
Nevada Employment Information - Required
Must be a registered pharmacy in Nevada, do not use the district office’s address
Pharmacy Name:
Address:
City:
State: NV Zip:
Date NABP application submitted:
Statement: I certify the above information is true and correct to the best of my
ability. Incorrect information may negate the approval or continuance of a temporary
license and issuance of permanent registration with the Nevada State Board of
Pharmacy. I must complete the permanent licensure within six months.
Signature
Date
For Board Use Only
State Verification:
/
/
Date
Good Standing
Expires
Employment Verification:
/
Date
Name of Person Verifying Employment
Date Temporary Issued:
Expires:
License #:
Nevada State Board of Pharmacy
Request for Approval of Temporary Pharmacist's License
Fax: (775) 850-1444
***A temporary license can not be applied for usless you have submitted the Nevada
application for reciprocation.*** Only pharmacists reciprocating to Nevada are eligible
for a temporary license. You can submit the form with your application or fax to the
number above. A temporary license is only valid for 6 months and can not be extended.
A Nevada address is required.
Name:
Nevada Address:
City:
State: NV Zip:
Telephone:
E-mail:
Reason for Temporary License:
Nevada Employment Information - Required
Must be a registered pharmacy in Nevada, do not use the district office’s address
Pharmacy Name:
Address:
City:
State: NV Zip:
Date NABP application submitted:
Statement: I certify the above information is true and correct to the best of my
ability. Incorrect information may negate the approval or continuance of a temporary
license and issuance of permanent registration with the Nevada State Board of
Pharmacy. I must complete the permanent licensure within six months.
Signature
Date
For Board Use Only
State Verification:
/
/
Date
Good Standing
Expires
Employment Verification:
/
Date
Name of Person Verifying Employment
Date Temporary Issued:
Expires:
License #: