Initial Application Forms
Animal Control Clinic Application, as defined in regulation part 10.10. For the procedure for initial licensure, click here.
Boarding and Residential Care Home Application. This is for any facility which provides care and services on a continuing basis for two or more in-house residents not related to the operator, and which maintains custody of the residents' drugs. This facility is explained in regulation part 11.9.
Changes. Use this form to report changes to the information on your license. Changes include a name change, change in home address, or a change in employment information. You may mail or fax this form or e-mail the changes directly to firstname.lastname@example.org.
Custodial Procedures Manual and Pharmacist Agreement for Boarding and Residential Care Homes. This manual does not supply the forms. The forms we supply are the receipt logs, the returned/destroyed logs, and a Pharmacist's Record of Visits log. You may download and print your own forms or contact our office and we will mail them to you.
Emergency Medical Services Clinic Application as defined in regulation part 24. For the procedure for initial licensure, click here.
Facility Controlled Substance Registration Application. For all facilities except for Methadone Clinics and facilities licensed as Analytical Labs, Teaching Institutes, or Controlled Substance Researchers.
Home Care Service Application as defined in regulation part 19. For the procedure for initial licensure, click here.
Hospital Pharmacy Application as defined in regulation part 7. For procedures on initial licensure, click here.
Intermediate Care Facility or Skilled Nursing Facility Drug Permit Application as defined in regulation part 11. Any facility, skilled nursing facility, intermediate care, or any other upper level of care facility as defined by Health and Human Services Department is required to maintain custody of patients' drugs in a drug room, and such drugs are administered by the facilities' designated personnel. For procedures for initial licensure, click here.
LAW ENFORCEMENT DRUG TAKE BACK APPLICATION.
Limited Controlled Substance Registration Application. Use this application if you are an Analytical Lab, a Teaching Institute, or a Controlled Substance Researcher.
Limited Drug Permit Clinic Application for clinics that are defined as a Public Health Clinic in regulation part 10.11. These clinics are licensed as A, B1, B2, B3, or C. For procedure for initial licensure, click here.
Limited Retail and Wholesale Veterinary Drug Permit. For facilities that sell dangerous drugs limited to veterinary use as defined in regulation part 15.
Narcotic Treatment Program Facility Controlled Substance Registration Application. This is for Methadone Clinics.
Nonresident Pharmacy Application as defined in regulation part 6.24. A Nonresident Pharmacy is a pharmacy located outside New Mexico that ships, mails, or delivers in any manner prescription drugs to New Mexico patients or consumers. A policy and procedure manual is required with the initial application. For the requirements of a nonresident policy and procedures manual click here.
Pharmacist Clinician Application as defined in regulation part 4.1. You will also need the Patient Contact log and instructions:
- Patient Contact Log Instructions
- Patient Contact Log
Pharmacy Application [DOC] as defined in regulation part 6, Procedure for Initial In-State Pharmacy Licensing.
Pharmacy Intern Registration as defined in regulation part 5. The Intern Packet is six different forms:
- Location to get approved name tag
- Intern evaluation of preceptor form
- Form to report hours earned
- Form to report change of work or living address
- Preceptor evaluation of intern form
- Preceptor application form
Pharmacist New Application as defined in regulation part 4.
Pharmacist Affidavit must be completed with initial pharmacist registration.
Pharmacist Application By Examination
Pharmacist Temporary Licensure Application
Practitioner's Controlled Substance Registration Application for individuals who are allowed to prescribe controlled substances. This license is required before the DEA will issue a federal controlled substance license.
Preceptor Application as defined in regulation part 5, for pharmacists supervising pharmacy interns.
Remodel or Relocation Application There is no fee for this, but you will also need a Request for Inspection.
Request for Inspection
Seller or Dispenser of Contact Lenses Application
Technician Application as defined in regulation part 22. Technicians must complete the Technician Training Record form below.
Technician Training Record Form required to be in every pharmacy where a technician works. Defined in regulation part 22.
Wholesale Drug Distributor Application defined in regulation part 8 and 9. For companies distributing drugs within New Mexico.
DEA Controlled Substance Registration Applications