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Lic form 2026
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- Click ‘Get Form’ to open the lic form in the editor.
- Begin by entering the Pharmacy Information. Fill in the Business Name and Physical Address of the pharmacy, ensuring accuracy as this information must match Box 2 on the Pharmacy Information Form.
- Next, provide your Full Legal Name, Title, Date of Birth, Texas Pharmacist License Number, and Social Security Number. Remember that your home address is confidential and must be filled out completely.
- Complete the Public Address section with an alternate address that can be shared publicly. You may use the same address as your home address if preferred.
- If applicable, list any other professional licenses you hold by providing the License Type, License Number, State, and Expiration Date.
- Answer all questions regarding professional disciplinary actions and criminal offenses truthfully. Ensure you provide additional details if necessary.
- Finally, attest to the accuracy of your information by signing and dating the form. Remember that this signature must be notarized before submission.
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lic surrender form pdf
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