License Change Form

Changes of information for a current Louisiana drug/device distributor license, such as changes to the facility and regulatory contact personnel, designated responsible party (DRP), revised lists of officers/directors or other states where licensure held, a copy of current valid home state license, or mailing address, should be submitted within 60 days after such changes become effective, per Board regulation./

NOTE: Changes to physical distribution address or business address (when a 3PLP is used for physical distribution and does not change) cannot BE CHANGED WITH THIS FORM. Louisiana licenses are NOT transferable with regards to location changes; applications for new licensure for the new distribution location are required.

1. PLEASE HAVE ALL REQUIRED DOCUMENTS READY for upload, when applicable, such as the completed DRP qualifications review form (for change of DRP), revised officers/directors list, new list of other states where licensure is held, and/or copy of current valid home state license (out-of-state licenses).
Designated Responsible Party Qualification Review Form
Note: Change of DRP for licensees physically located in Louisiana ONLY requires criminal history records (background) check, Criminal history records check documents must be submitted to the Board office via USPS/carrier including: Board Authorization form, LA State Police Disclosure form, Fingerprint Card (obtained from local law enforcement agency), and fee payment of $39.25 payable to LA Dept. of Public Safety.
2. ENTER below the Louisiana license number for the change in license information request. PLEASE CHECK THE LICENSE NAME provided on the form that comes up to verify the correct Louisiana license number was provided.
3. COMPLETE the information change request form.
4. PRINT a copy of the completed information form for your records BEFORE submitting the form.

License Number: