PHY et al renewal form (Rev 6 2012) smaller size doc-2026

1. Click ‘Get Form’ to open the PHY et al renewal form in the editor.
2. Begin by entering the 'Name of Pharmacy/Clinic' in the designated field. Ensure that this matches your official records.
3. Next, input your 'License Number' and 'Expire Date'. Double-check these details for accuracy as they are crucial for processing your renewal.
4. Fill in your 'Telephone Number' and 'Address'. This information is essential for communication regarding your application.
5. Proceed to the certification section. The owner or authorized individual must sign and print their name, along with the date, confirming no changes have occurred since the last renewal.
6. Finally, ensure that the Pharmacist-in-Charge also signs and prints their name with the date, certifying that all statements are true and accurate.

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