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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: P.O. Box 8935 FAX #: Phone #: Madison, WI 53708-8935 (608) 261-7083 (608) 266-2112 PHARMACY EXAMINING BOARD OUT-OF-STATE PHARMACY LICENSE APPLICATION 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. ยง 440.14) 1400 E. Washington Avenue Madison, WI 53703 E-Mail: web@dsps.wi.gov Website: http://dsps.wi.gov NEW PHARMACY APPLICATION CURRENT WI LICENSE NO.: CHANGE OF OWNERSHIP ___________________________ CHANGE OF LOCATION PLEASE TYPE OR PRINT IN INK. APPLICANT: DBA: individual, partnership, association or corporation TELEPHONE NO. FAX NO. ( ( ) ) Name or title under which business is operated. (This must be the name on the pharmacy label.) PHARMACY ADDRESS: MAILING ADDRESS: number, street, city, zip code number, street, city, zip code COUNTY NAME OF OWNER OR NAMES AND TITLES OF ALL PARTNERS OR CORPORATE OFFICERS AND PERCENTAGE OF OWNERSHIP. (Attach additional sheets if necessary.) NAME % NAME % _____________________________________________ _____________________________________________ _______ _______ ______________________________________________ ______________________________________________ State: ___________________________ License Number: ___________________________ ________ ________ Pharmacy license number in state where the pharmacy is physically located. Enclose copy of current license, permit, or registration certificate issued by the regulatory authority of the home state or territory OR letter from such authority certifying the pharmacy's compliance with the pharmacy and controlled substances laws of the home state. Enclosed (check one): Managing Pharmacist DATE OF PURCHASE OF PHARMACY - date of sale to be signed (For Change of Ownership only) license compliance letter State License # PROPOSED OPENING DATE (This is required for a Change in Ownership or Change in Location.) PROPOSED CLOSE DATE OF CURRENT LICENSE # (This is required for a Change in Ownership or Change in Location.) PHARMACY HOURS - Daily (open - close) An 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 Wisconsion for not less than 40 hours per week. The label of all prescription drug containers shiopped, mailed or otherwise delivered to a person in Wisconsoin must bear the telephone number of the out-of-state pharmacy. Telephone No.: ( ) - For Receipting Use Only APPLICATION FEE: Please make check payable to Department of Safety and Professional Services and attach to application. $75.00 #2737 (Rev. 9/11) Ch. 450, Stats. Initial Credential Fee -OVERAmerican LegalNet, Inc. www.FormsWorkFlow.com Committed to Equal Opportunity in Employment and Licensing American LegalNet, Inc. www.FormsWorkFlow.com Wisconsin Department of Safety and Professional Services Statement of Owner or Managing Pharmacist Statement from the owner of the pharmacy or; If the pharmacy is not a sole proprietorship, from the managing pharmacist of the pharmacy; This is to certify that I have read and approved the foregoing and the statements are true and correct to the best of my knowledge and belief; and that I know the laws relating to the practice of pharmacy in Wisconsin. ___________________________________________________ (Owner, if a sole proprietorship) ____________________________________ Date ___________________________________________________ PRINTED NAME This is to certify that I have read and approved the foregoing and the statements are true and correct to the best of my knowledge and belief; and that I know the laws relating to the practice of pharmacy in Wisconsin. ___________________________________________________ (Managing Pharmacist, if not a sole proprietorship) ____________________________________ Date ___________________________________________________ PRINTED NAME State License # ______________________________________ American LegalNet, Inc. www.FormsWorkFlow.com
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