Follow the steps to successfully complete the TX LIC-021 form online.

1. Press the ‘Get Form’ button to access the TX LIC-021 form and open it in your preferred online editor.
2. Begin by entering the business name of the pharmacy in the designated field. Ensure that this matches the information provided in Box 2 on the pharmacy information form.
3. Provide the physical address of the pharmacy, including the street address, city, state, and zip/postal code.
4. Fill in the full legal name of the individual managing officer in the corresponding section.
5. Enter the title of the officer, along with the date of birth formatted as mm/dd/yyyy, and the Texas Pharmacist License number if applicable.
6. Input the required home address, which will be treated as the confidential address of record. This includes the street address, city, state, and zip/postal code.
7. Include a phone number for the individual, whether it be a home, cell, or main phone number.
8. Enter a public address that may be released to the public, which must also include the street address, city, state, and zip/postal code. This field is mandatory.
9. If the individual holds any other professional licenses, provide the necessary details including license type, number, state, and expiration date.
10. Answer the mandatory questions regarding professional disciplinary actions and criminal offenses, providing additional information if applicable.
11. Finish by attesting to the accuracy of the information provided. The signature of the owner/managing officer must be notarized.
12. Before submission, ensure that a copy of the current Driver’s License and Social Security Card is attached. Save your changes, download the completed form, print it, and prepare to submit the original notarized form, as copies or faxes will not be accepted.

Complete your application promptly by filling out the TX LIC-021 form online today.