Secretary of State Professional Licensing Boards Division ...
(478) 207 -1640
Secretary of State Professional Licensing Boards Division
Georgia Board of Pharmacy
237 Coliseum Drive Macon, Georgia 31217
(Fax) 207 -1660
ORDER FORM
for DUPLICATE LICENSE CARDS AND LICENSE VERIFICATIONS
To request a duplicate license card or a license verification, please complete the following form and enclose a check or money order in the amount of $25.00 made payable to the Board of the applicable profession and mail to the address listed above.
Request for:
Duplicate Pocket-License Card
License Verification
Profession:
Pharmacist
Retail Pharmacy Prison Pharmacy Pharmacy Researcher
Nuclear Pharmacist
Hospital Pharmacy Pharmacy Clinic Wholesaler
Pharmacy Intern
Nuclear Pharmacy Pharmacy School Manufacturer
License #:______________________
Name of licensee or facility: __________________________________________
(Please print CLEARLY)
Address/Location: _________________________________________________
(Street or PO Box)
________________________________________________________________________
(City)
(State)
(Zip)
Phone #: (_____)_________________
? For Verification of license requests, please indicate where verification should be mailed if different from above:
_______________________________________________________
(Name or Agency Name)
_______________________________________________________
(Mailing Address)
(City)
(State)
(Zip)
................
................
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