Board of Health - Nebraska Department of Health and Human 2025

1. Click ‘Get Form’ to open the application in the editor.
2. Begin with Section A, where you will input the Pharmacy Inspector’s Name, Pharmacy Name, License Number, and Pharmacy Address. Ensure all details are accurate for a smooth processing.
3. Next, provide information about the Owner(s), Partners, or Corporation. If applicable, include the names of Corporate Officers.
4. In Section B, select the reason for amending your pharmacy license. Fill in details such as Effective Date of Change and relevant license numbers for changes in Pharmacist-in-Charge or name changes.
5. Complete Section C by signing the affidavit. Ensure that the signature is from an authorized person and that all statements are true.
6. Finally, review all sections for accuracy before submitting your completed form along with any required documents to the Department.

Start using our platform today to streamline your document editing and submission process for free!