Follow the steps to fill out the LA Form 58 online with ease.

1. Click ‘Get Form’ button to access the document and open it in the online editor.
2. Complete Section 1 by entering your pharmacy name and permit number. Provide the physical address, city, state, ZIP code, and parish. Also, include an email address that can be used for official communications.
3. Identify the pharmacist-in-charge by providing their name and LA PST license number. Ensure the information matches current Board records.
4. Respond to the special survey questions by selecting 'Yes' or 'No' as applicable to your pharmacy's operations regarding compounding and dispensing.
5. In Section 2, answer questions related to any unfilled positions within your pharmacy for both pharmacists and certified pharmacy technicians.
6. In Section 3, disclose any disciplinary history by answering the necessary questions. If you answer 'Yes' to any question, prepare the required attachments, including a letter of explanation and certified documentation.
7. In Section 4, review the fee structure and calculate the total due. If you choose to opt out of the pharmacy education support fee, check the appropriate box.
8. Complete the attestation in Section 5 by signing and dating the application, certifying the accuracy of the information provided.
9. Once all sections are filled out, save your changes. You may then download the completed form, print it, or share it as necessary.

Ensure your application is submitted correctly by completing the LA Form 58 online today.