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New Mexico Regulation and Licensing Department BOARDS AND COMM ISSIONS DIVISION Board of Pharmacy 5200 O ak lan d A v en u e, N E Su it e A A lb uqu erq u e, N ew Mexi co 8711 3 ( 505) 222 -9830 Fax ( 505) 222 -9845 ( 800) 565 -91 0 2 h tt p :/ / www.r ld .s ta t e.nm .us /b oa r ds/ ph a rma cy.as px FEE: $400.00 Biennial (Please pay by check or money order) Our office must receive application and fees at the same time; otherwise processing time will be delayed. Retain a copy of both the renewal form and form of payment for future references. NAME & MAILING ADDRESS: NAME & STREET ADDRESS: NONRESIDENT PHARMACY APPLICATION __________________________________ __________________________________ __________________________________ PHONE NO:___________________________ EMAIL: ______________________________ __________________________________ __________________________________ ___________________________________ FAX NO: _____________________________ WEB ADDRESS ______________________ Contact Person Name and Title: __________________________________________ Telephone Number _______________ REQUIRED TOLL FREE NUMBER FOR NEW MEXICO RESIDENTS: ___________________________ Check Appropriate Box: NEW CHANGE OF OWNERSHIP current license number PH_______________ I, (we) the undersigned, hereby apply for a license to operate a Pharmacy under the Pharmacy Laws of the State of New Mexico and present the following statements in support of the privilege to be granted a license and represent that if such license is granted, such place will be conducted in full compliance with existing Pharmacy laws, and rules and regulations of the Board of Pharmacy unless compliance would violate the laws and regulations of the resident state. I (we) hereby understand that the license expires December 31 of every other year, that the license is not transferable, and that a separate license is required for each pharmacy location. Please make sure 1-9 are all answered or attached to this application before submittal, if not it will be returned. Enter current registration numbers; "pending" if applying for; or "N/A" if not applicable. a) Federal DEA Reg. No._______________________ b) New Mexico Controlled Substance Registration No.________________________ c) Resident State Controlled Substance Registration No.______________________ d) A New Mexico Controlled Substance license is required for shipping/mailing controlled substances into New Mexico. 2. Circle the Letter beside appropriate classification: (If b, c, or d please attach list on a separate piece of paper) a) If individual is owner, give name and address; b) If a partnership is owner, give name and address of all partners, (attach list); c) If a corporation or municipality, list name, address and title of all officers, (attach list); d) If county, city, state or church is owner, give name, address and title of all officers, (attach list); 3. Attach copy of current resident state license, permit or registration to operate a pharmacy. 4. Attach a copy of the most recent inspection conducted by the resident state regulatory or licensing agency. 5. All applicants submit a policy & procedure manual as required by the New Mexico Board of Pharmacy Rules & Regulations. The policy and procedures manual as defined in 16 NMAC 19.6.24.C1(d) & D(2). This manual will have the following policies: Do not send entire policy manual, only the four items listed below. All items must be labeled. a) Normal delivery protocols and times; b) The procedures to be followed if the patient's medication is not available at the Nonresident Pharmacy, or if the delivery will be delayed beyond the normal delivery time; c) The procedure to be followed upon receipt of a prescription for an acute illness, which policy shall include a procedure for delivery of the medication to the patient from the Nonresident Pharmacy at the earliest possible time (i.e. courier delivery), or an alternative that assures the patient the opportunity to obtain the medication at the earliest possible time; d) The procedure to be followed when the Nonresident Pharmacy is advised that the patient's medication has not been received within the normal delivery time and that the patient requires interim dosage until mailed prescription drugs becomes available. 6. Attach a list of the name and address of a resident agent in New Mexico for service of process. 7. List all other states where licensed, license number and expiration date. (attach list) 8. Attach a letter describing in detail the nature of your business in the State of New Mexico. 9. List all trade or business names ("DBA" names) previously or currently used by same corporation or by licensee: __________________________________________________________________________________________________ I, (we) have not been arrested, investigated for, charged with, convicted of, sentenced, entered a plea of non contendere, or entered into any other legal agreements for any criminal offense in any state, territory or possession of the United States or by the federal government.* Signature________________________________________________ I, (we) do not have any disciplinary actions, or any pending actions against me/the pharmacy, or to my knowledge been investigated by any professional licensing authority.* Signature________________________________________________ *If the above statements are not true, explain the circumstances, include a copy of the judgment, and attach to this application. I (we) hereby certify that the information given in this application is true and correct to the best of my (our) knowledge. ___________________________________________________________ ________________________ Signature Print Name & Title - Owner or Officer Date signed _________________________________________ ___________________ ________________________ Signature Print Name of Pharmacist-in-Charge License # Date signed 1. Please complete Non Resident Self-Assessment on the back of this application. Revision date: 08/2013 American LegalNet, Inc. www.FormsWorkFlow.com New Mexico Regulation and Licensing Department BOARDS AND COMM ISSIONS DIVISION Board of Pharmacy 5200 O ak lan d A v en u e, N E Su it e A A lb uqu erq u e, N ew Mexi co 8711 3 ( 505) 222 -9830 Fax ( 505) 222 -9845 ( 800) 565 -91 0 2 h tt p :/ / www.r ld .s ta t e.nm .us /b oa r ds/ ph a rma cy.as px Non-Resident Pharmacy Self-Assessment Form The Pharmacist-In-Charge is responsible for completing this self-assessment form. Please