Get Ks Form Ba-11 2017-2025

Filling out the KS Form BA-11 online is a straightforward process designed to facilitate the registration application for county health or family planning. This guide will provide you with clear and concise instructions to complete each section of the form effectively.

Follow the steps to complete the KS Form BA-11 online.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by indicating whether you are submitting a new application or making a change. Check the appropriate box for 'New Application' or 'Change' and specify what is being changed.
3. Provide your ownership details. If the owner is a corporate or legal entity, ensure to complete and attach the appropriate Ownership Form (S-310 for Partnership, S-320 for LLC, or S-330 for Corporation). Fill in the owner’s name, address, contact details, and ownership type, along with the necessary identification numbers (SSN or FEIN).
4. Fill in the department or clinic information, including the name of the facility, hours per week that a pharmacist is on duty, and the physical address of the clinic.
5. If applicable, provide details about the authorized agent, including their name, title, contact information, and designate where formal correspondence should be sent by checking the appropriate box.
6. List the pharmacists working at the facility. Include their names and license numbers. If more space is needed, attach additional pages.
7. Complete the PIC certification section by declaring your role as pharmacist-in-charge, signing, and dating the application.
8. Review the form for accuracy and completeness, ensuring that all required fields are filled out and supporting documentation is attached.
9. Once satisfied with your entries, you can save changes, download, print, or share the completed form as needed.

Begin filling out the KS Form BA-11 online today to ensure your application is submitted accurately.