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Out-Of-State Pharmacy License Application 2737 - Wisconsin

Out-Of-State Pharmacy License Application Form. This is a Wisconsin form and can be used in Pharmacy Examining Board Statewide .
 Fillable pdf Last Modified 11/17/2011
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Wisconsin Department of Safety and Professional Services Mail To: FAX #: Phone #: P.O. Box 8935 Madison, WI 53708-8935 (608) 261-7083 (608) 266-2112 Ship To: 1400 E. Washington Avenue Madison, WI 53703 E-Mail: dsps@wisconsin.gov Website: http://dsps.wi.gov PHARMACY EXAMINING BOARD LICENSURE FOR OUT-OF-STATE PHARMACY AN APPLICATION IS NOT COMPLETE UNTIL ALL OF THE FOLLOWING DOCUMENTS HAVE BEEN RECEIVED: A completed application must be on file at least 30-days prior to proposed opening date. To license a New Pharmacy with the Pharmacy Examining Board, complete the Application for the Licensure of an Out-of-State Pharmacy (Form #2737), making sure to provide all information requested. To re-license a pharmacy because of a Change of Ownership or Location Change, complete the Application for the Licensure of an Out-of-State Pharmacy" (Form #2737), making sure to provide all information requested. No Pharmacy that is in another state may ship, mail, or otherwise deliver a prescribed drug or device to persons in Wisconsin unless the Pharmacy is licensed in Wisconsin (Wis. State Stat. § 450.065). An Out-of-State Pharmacy that applies for a license is not required to comply with Wisconsin law relating to the professional service area of a Pharmacy or the minimum equipment requirements for a pharmacy. A Pharmacist employed in an Out-of-State Pharmacy is not required to be licensed in Wisconsin. A licensed Out-of-State Pharmacy is not required to be under the control of a Managing Pharmacist licensed in Wisconsin. A licensed Out-of-State Pharmacy shall provide a telephone number that allows a person in Wisconsin to contact the Pharmacy during the Pharmacy's regular hours of business and that is available for use by a person in Wisconsin for not less than 40 hours per week. The label of all prescription drug containers shipped, mailed, or otherwise delivered to a person in Wisconsin must bear the telephone number of the Out-of-State Pharmacy. Wis. State Stat. § 450.06 (3), requires that a new pharmacy license be obtained following a change of ownership. The following chart sets forth when a change of ownership is deemed to have occurred or not occurred. Following the issuance of a new license, that new licensee must also renew that new license at the next required renewal date, regardless of when that new license was issued. OWNER TRANSACTION CHANGE OF OWNERSHIP? Yes No Yes Yes Yes No No No Yes No Individual Individual Individual Partnership Partnership Partnership Partnership Corporation Corporation Corporation i Sells pharmacy to another "Incorporates" him or herself and there are no other shareholders. Incorporates and adds shareholders other than self, or goes into partnership with other(s). Sells pharmacy to another Members of partnership change and dissolves; e.g., individual(s) leaves. Members of partnership change, but partners vote not to dissolve unanimously or by partnership agreement. Partnership decides to incorporate itself Change in shareholders (including sale of all stock) Sells all assets (as opposed to stock) Becomes a subsidiary or division of another corporation. Wis. Stat. § 450.06(3), provides in relevant part as follows: No pharmacy may be opened or kept open for practice following a change of ownership . . . unless the pharmacy is licensed for the new owner . . . notwithstanding any remaining period of validity under the pharmacy's license under the previous owner . . . i Limited Liability Companies created under Wis. Stat. § 183, are the same as Corporations for change of ownership. #2737 (Rev. 12/16) Ch. 450, Stats. Committed to Equal Opportunity in Employment and Licensing i American LegalNet, Inc. www.FormsWorkFlow.com Wisconsin Department of Safety and Professional Services Mail To: FAX #: Phone #: P.O. Box 8935 Madison, WI 53708-8935 (608) 261-7083 (608) 266-2112 Ship To: 1400 E. Washington Avenue Madison, WI 53703 E-Mail: dsps@wisconsin.gov Website: http://dsps.wi.gov PHARMACY EXAMINING BOARD LICENSURE FOR OUT-OF-STATE PHARMACY Under Wisconsin law, the Department must deny your application if you are liable for delinquent State Taxes or Child Support (Wis. Stats. § 440.12). PLEASE TYPE OR PRINT IN INK Your name and address are available to the public. Check box to withhold street address/PO Box number from lists of 10 or more credential holders (Wis. Stat. § 440.14). New Pharmacy Application (never held a WI license) Current WI License #: (list current WI license number and choose option below) Change of Ownership Pharmacy Application Change of Location Pharmacy Application Your Social Security Number or Employer Identification Number must be submitted with your application on this form. If you do not have a Social Security Number, you must complete Form #1051. The Department may not disclose the Social Security Number collected except as authorized by law. FEIN # - Applicant Name (individual, partnership, association, or corporation) Pharmacy DBA Name (name or title under which business is operated, this must be the name on the pharmacy label) Pharmacy Address (street, city, state, zip) Telephone Number Mailing Address (if different) Fax Number - Pharmacy Email Address Name of Owner or Names and Titles of all Partners or Corporate Officers and Percentage of Ownership (attach additional sheets if necessary) Name % Name % Enclose copy of current license, permit, or registration certificate issued by the regulatory authority of the home state or territory OR a letter from such authority certifying the Pharmacy's compliance with the pharmacy and controlled substances laws of the home state. Enclosed (check one): License Compliance Letter For Receipting Use Only (43) APPLICATION FEES: Please check applicable box. Make check payable to DSPS and attach to this application. Initial Credential Fee $ 75.00 Initial Credential Fee $ 75.00 Total Fee Attached #2737 (Rev. 12/16) Ch. 450, Stats. Committed to Equal Opportunity in Employment and Licensing Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Wisconsin Department of Safety and Professional Services APPLICATION IS NOT COMPLETE UNTIL ALL OF THE FOLLOWING DOCUMENTS HAVE BEEN RECEIVED: Application (Form #2737) and appropriate fee Proposed Opening Date (Required for a Change-in-Ownership or a Change­in-Location.) Proposed Close Date of Current License # (Required for a Change-in-Ownership or a Change-in-Location.) Date of Purchase of Pharmacy (Date of Sale to be signed, for a Change-inOwnership only.) / / /
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