:: Initial Applications ::

Waiver of Fee -- Determination of Eligibility

An applicant for an initial license or registration is eligible for a waiver of the initial fee(s) if the applicant’s adjusted gross household income does not exceed 200% of the Federal Poverty Level and the applicant is applying for this specific license/registration category for the first time.

To determine eligibility, you must first identify the number of individuals in your household. Once this is determined, reference the Federal Poverty Level and identify your adjusted gross income that matches the number of individuals in your household. If your adjusted gross household income, as reported on your most recent federal tax return, is less than the identified value, you are eligible for the one-time fee waiver.

If you determine that you are eligible for the one-time fee waiver, you will be provided an opportunity to request the waiver at the end of this application. You will also be required to upload a copy of your household Federal Tax Return for the preceding year.

If you are married and filed separately, you will need to submit the Federal Tax Return for both your spouse and yourself.
If you were claimed as a dependent on another person’s tax return, you will need to submit the Federal Tax Return for the tax filer who claimed you as a dependent.

Please be sure you have the required documents ready before proceeding with this application. If your documents are not available for upload when the waiver opportunity is presented, you will need to redo this entire application to request a fee waiver.

Pharmacy Support Person (PSP)

You are applying for a Pharmacy Support Person (PSP) registration. Prior to commencing pharmacy support employment, a PSP registration is required for individuals who will be employed in a pharmacy, under the supervision of a pharmacist, to assist the pharmacist with nontechnical duties associated with the practice of pharmacy.

Registrations are issued administratively following review of a completed application and all required documentation, unless the application warrants referral to the Board or unless a personal appearance is required. You will be contacted if any of these exceptions apply to you.

Applications are valid for only 45 days from the date of receipt. You will be notified by email if additional information is required. If the application has not been completed within 45 days, a new application and fee must be submitted if you wish to obtain an Iowa PSP registration.

Failure to answer all questions completely or accurately, and/or omission or falsification of material facts, may be cause for denial of your application, or disciplinary action if you are subsequently registered by the Board. If you are in doubt, answer “yes” and provide an explanation.

A pharmacy support person must report to the Board a change of name, address, email address, place of employment, or employment status within ten days of the change.

Iowa Regulations

657 Iowa Administrative Code Chapter 5 governs the practice of a PSP in an Iowa pharmacy.

Have you reviewed and do you understand the Iowa regulations pertaining to PSPs?

Yes

Required Documents

A Government-Issued Photo Identification (driver’s license, government issued ID, passport, etc.) is required to be uploaded with your application.

In addition, the following documents may be required to be uploaded with your application:

1. Description and documentation of the conviction(s) for any criminal history disclosed.

a. You are strongly encouraged to perform a background check on yourself or to have your employer perform one prior to submitting your application. To search Iowa Courts online go to https://www.iowacourts.state.ia.us/ESAWebApp/DefaultFrame and click “Start a Case Search Here.” Keep in mind that this database only shows Iowa state court convictions. These instructions are not intended to provide a comprehensive criminal history background check, but rather a quick way for you to refresh your memory as to any Iowa state court convictions.
b. You must disclose all convictions, regardless of where they occurred. Failure to disclose a criminal conviction could result in delays in processing your application or in your application being denied.

2. Description and documentation of the final disciplinary order(s) for any disciplinary history disclosed
3. Description and documentation of the final denial order(s) by a licensing authority.

Military or Veteran Status

1.Are you active duty military?

Yes

2.Are you a military veteran?

Yes

3.Are you the spouse of an active duty military member or veteran?

Yes

Prior Iowa Board of Pharmacy Licensure or Registration

Have you ever been licensed or registered with the Iowa Board of Pharmacy in any capacity?

Yes

Full Name

Street Address

C S Z

License/Registration #

License/Registration Type

License Status

Expiration Date

Personal Information

Provide Full Legal Name

Last Name

First Name

Middle Name

Suffix

Maiden Name

Date of Birth

Social Security #

Gender

Home/Permanent Address

Address 1

Address 2

Address 3

Country

Zip

City

State

County

Mailing Address

Check if mailing address is the same as physical address

Address 1

Address 2

Address 3

Country

Zip

City

State

County

PSP Contact Information

Phone Type

Primary Phone #

Will you accept text messages?

Yes

Alternate Phone Type

Alternate Phone #

Will you accept text messages?

Yes

E-mail

Fax #

Current Employment

Iowa rules require that a registration be issued prior to the individual commencing work in a pharmacy. “Employment” means that you have been hired by a pharmacy, not necessarily that you have actually started working in the pharmacy. Please identify the pharmacy that has hired you and the date of hire to physically work within the pharmacy. If you have been working for a company in another capacity, but are just now to begin the duties of a pharmacy employee, indicate the date you are hired to perform duties for the pharmacy, not the initial date you were hired to work elsewhere within the company.

Do not indicate that you are not currently employed in a licensed Iowa pharmacy if you have been hired to work in a licensed Iowa pharmacy.

Are you currently employed in a licensed Iowa pharmacy?

Yes

Other State Professional Licenses or Registrations

Do you or have you ever held a professional license/registration in Iowa or another state (do not include driver’s license information)?

Yes

Criminal History

Have you ever been convicted of or entered a plea of guilty, nolo contendere, or no contest to any crime in any jurisdiction? All convictions, except for minor traffic offenses, must be disclosed. “Conviction” means a finding, plea, or verdict of guilt made or returned in a criminal proceeding, even if the adjudication of guilt is deferred, withheld, or not entered. “Conviction” includes Alford pleas and pleas of nolo contendere. You must submit the complaint and judgment of conviction for each offense in addition to a personal statement regarding whether each conviction directly relates to the practice of pharmacy. Your application will not be considered complete until the entirety of this information is received by the Board.

Yes

Disciplinary Actions/History

Have you ever been disciplined by any licensing authority? Discipline includes, but is not limited to, citations, reprimands, fines, and license/registration restrictions, probation, suspension, revocation, or surrender. ?

Yes

License/Registration Denials

Have you ever been denied a license or registration by any licensing authority?

Yes

Pending Investigations

Do you have any charges, or knowledge of any investigations or complaints, pending before any licensing authority?

Yes

Required Document(s)

Illegible copies of any attached documents will not be accepted.

Upload a copy of Government Issued Identification (i.e. driver’s license, government issued ID, passport, etc.)

Preview

Please review your application and return, using the Previous button, to any page(s) that needs to be changed or corrected.
Once you click the Next button on this page you will not be able to make any changes to your application.

Confirm and Submit

I hereby swear or affirm under the penalty of perjury that the information provided in this application is true and correct. I understand that failure to provide complete and truthful information may constitute grounds for denial, revocation, or other disciplinary sanctions against my pharmacy support person registration. Information provided on this application may be disclosed pursuant to 657 IAC Chapter 14, subject to exceptions in federal and state law.

Signature

Date

Please allow 5-7 business days for processing.

You may check the status of a pending application at https://pharmacy.iowa.gov/initial-application-status-check

Once your registration has been issued it can be verified at https://pharmacy.iowa.gov/online-services/licenseregistration-verification

License/Registration Type

State Licensing Body

License/Registration number

License/Registration Status

License/Registration issue date

License/Registration expire date

License Type

License Number

Business Name

Address

Zip

City

State

Name of the PIC

Pharmacy email address

Exact date of hire as a PSP, when you began working as a PSP in the secured pharmacy area

Pharmacy Support Person (PSP) Initial Application