Request for Duplicate License Certificate

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. HAVE PAYMENT TOOLS AVAILABLE and ready, such as a major credit card of bank account information for e-check payment. $10 duplicate license certificate fee requires (per LAC 46:XXXIV.801.A.4).

2. ENTER THE LOUISIANA LICENSE NUMBER and the LAST LICENSE RENEWAL assigned PIN below, for NEW LICENSE ISSUES or if renewal PIN not available, contact the Board office to receive a temporary PIN which will be valid for three days upon receipt. VERIFY THE LICENSEE NAME that is provided on the next format that opens to confirm the correct Louisiana license number was provided.

3. COMPLETE the request form.

4. Print a copy of the completed request form for your records BEFORE submitting the request. Qualification Review Form