┌──┬───────┬──┬─┬──┬───┬───┬────┐
│姓名│              │性别│  │职务│      │职称  │        │
├──┴───────┼──┴─┴──┴───┴───┴────┤
│身份证号码          │                                        │
├──────────┼────────────────────┤
│执业药师注册证号码  │                                        │
├──────────┼────────────────────┤
│执业药师资格证书号码│                                        │
├──────────┼────────────────────┤
│继续教育登记证书号码│                                        │
├──────┬───┴───┬──────┬─────────┤
│首次注册年份│              │上次注册年份│                  │
├──────┼───────┼──────┼─────────┤
│执业类别    │药学  中药学  │执业范围    │生产  经营  使用  │
├──────┼───────┴──────┼───┬─────┤
│执业单位名称│                            │现岗位│          │
├──────┼──────────────┼───┼─────┤
│执业单位地址│                            │邮编  │          │
├──────┼───┬──────────┼───┼─────┤
│联系电话    │单位  │                    │住宅  │          │
├─┬────┴───┴──────────┴───┴─────┤
│近│                                                          │
│三│                                                          │
│年│                                                          │
│来│                                                          │
│主│                                                          │
│要│                                                          │
│业│                                                          │
│绩│                                                          │
│及│                                                          │
│奖│                                                          │
│惩│                                                          │
│情│                                                          │
│况│                                                          │
└─┴─────────────────────────────┘


┌───┬──────────────────────┬────┐
│      │      主          要        内        容    │学时学分│
│      ├──────────────────────┼────┤
│      │                                            │        │
│上次  │                                            │        │
│注册  │                                            │        │
│后的  │                                            │        │
│继续  │                                            │        │
│教育  │                                            │        │
│情况  │                                            │        │
│      │                                            │        │
│      │                                            │        │
│      │                                            │        │
├───┼──────────────────────┴────┤
│执    │                                                      │
│业    │                                                      │
│单    │                                                      │
│位    │                                                      │
│考    │                                                      │
│核    │                                                      │
│意    │负责人                                    （公章）    │
│见    │                                         年  月  日   │
├───┼───────────────────────────┤
│省级药│                                                      │
│品监督│                                                      │
│管理局│                                                      │
│审查意│负责人                                    （公章）    │
│  见  │                                         年  月  日   │
├───┼───────────────────────────┤
│备    │                                                      │
│注    │                                                      │
└───┴───────────────────────────┘

注：本表一式四份，报送国家药品监督管理局一份。

附表三（样表） 编号:

执业药师变更注册登记表

注册地区： 省（自治区、直辖市） 变更时间： 年 月 日