Minnesota > Statewide > Board Of Pharmacy
Application For A Pharmacy License - Minnesota
| Application For A Pharmacy License Form. This is a Minnesota form and can be used in Board Of Pharmacy Statewide . |
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2829 UNIVERSITY AVE SE #530, MINNEAPOLIS, MN 55414-3251 Phone: (651) 201-2825 Fax: (651) 201-2837 Relay Service: Metro Area (651) 297-5353 Non-Metro Area 800-627-3529 E-Mail: pharmacy.board@state.mn.us - Web: www.phcybrd.state.mn.us MINNESOTA BOARD OF PHARMACY APPLICATION FOR A PHARMACY LICENSE LICENSE EXPIRES JUNE 30 OF EACH YEAR *As of October 1, 2010, license and registration fees include a 10% electronic licensing surcharge, with a $5.00 minimum. These funds are sent to the Minnesota Office of Enterprise Technology to implement one portion of a state electronic licensing system. The surcharge will be in place through June 15, 2015. FEE FOR NEW PHARMACY AND OWNERSHIP CHANGE: $190.00 + $19.00* = $209.00 NO FEE FOR NAME CHANGE OR ADDRESS CHANGE Make Check Payable to: Minnesota Board of Pharmacy NO RETURN OR REFUND OF FEES State of Minnesota Taxpayer Identification Number: Federal 41-6007162 - State 4405717 NEW PHARMACY: Date of proposed opening in Minnesota CHANGE IN: Date of proposed change Ownership Formerly: __________________________________________________ Name Formerly: __________________________________________________ Address Formerly: __________________________________________________ Location/dimension/physical layout - Please attach copies of the plans or a sketch of the new location or a remodel. Make sure the plans or sketches provide the dimensions of the pharmacy and of features such as countertops and the counseling area. Amount of space being licensed: ___________ square feet HOURS: M-F _________ to _________ Saturday _________ to _________ Sunday _________ to ________ PHONE NUMBER: __________________________ FAX NUMBER: ___________________________ E-MAIL ADDRESS: _______________________________________________________________________ 1. Print, type, or check all applicable boxes. Pharmacy Name: ________________________________________________________________________ Street Address: __________________________________________________________________________ City, State, Zip: ___________________________________________________________________________ 2. Check the appropriate item and complete ownership information: Sole Proprietor; Partnership; Limited Liability Partnership; Corporation; Limited Liability Corp Fill in: Name of Sole Proprietor, Partnership, or Corporation: ________________________________________________________________________________ Address:_______________________________________________________________________________ City, State, Zip: _________________________________________________________________________ Partnership or Limited Liability Partnership: List all active and inactive partners. If a new partnership or limited liability partnership, please attach a copy of the partnership papers. Name Address RPh? % of Ownership Rev 4/11 American LegalNet, Inc. www.FormsWorkFlow.com Corporation or Limited Liability Corporation: List all shareholders owning 20% or more of the voting stock, all officers and their titles. If a new Corporation or Limited Liability Corporation, please attach corporation papers. Name Address RPh? % of Ownership List the state of incorporation: ___________________________________________________________________ List the number of shares of common or voting stock issued: ___________________________________________ All pharmacies, in-state and out-state should answer the following questions: 3. Please check all categories of licensure that apply to your pharmacy. A. Community/Outpatient B. Hospital C. Home Health Care D. Long Term Care E. Nuclear F. Central Service G. Limited Service* H. Nonsterile Product Compounding I. Sterile Product Compounding J. Veterinary K. Non-Resident L. Federal * Please submit a description of the services that you propose to provide. 4. Does the owner of this pharmacy own 4 or more pharmacies under this ownership: 5. Employees: (Please attach another sheet if necessary) Pharmacist Name Full-time and Part-time License # Yes No Hrs Per Week Technician Name Full-time and Part-time Regis. # Hrs Per Week 6. Please answer the following: (a) On behalf of the owner, if the applicant is a sole proprietorship (b) On behalf of each partner, if the applicant is a partnership or a limited liability partnership (c) On behalf of the corporation, if the applicant is a corporation or a limited liability corporation, and on behalf of each officer, director, or shareholder owning 20% or more of the voting stock of the corporation. a. Has the applicant been convicted in any court of a felony? Yes No b. Has the applicant habitually indulged in the illegal use of narcotics, stimulants, or depressant drugs; or habitually indulged in intoxicating liquors in a manner which could cause incompetence in the practice Yes No of pharmacy? c. Has the applicant ever made application for a license to operate a pharmacy in this state or any other state? Yes No (1) If yes, was the application denied by the Board of Pharmacy? Yes No (2) If denied, for what reason? ____________________________________________________ (3) If the license was granted, was it later suspended, revoked, or placed on probation? Rev 4/11 American LegalNet, Inc. www.FormsWorkFlow.com Yes No (4) Did the Board, in connection with any violations, issue any warnings or reprimands? Yes No (5) If yes, what was the nature of the violation? ______________________________________ d. Has the applicant been convicted of theft of drugs or the unauthorized use, possession, or sale thereof? Yes No MINNESOTA IN-STATE PHARMACIES PLEASE COMPLETE #7 12. 7. PLEASE COMPLETE THE FOLLOWING: 1981 Laws, Chapter 346 requires that you supply us with information concerning your worker's compensation insurance, for this firm, prior to the issuance of the license. Please check the applicable box below: Self-insured, please attach a copy of the Certificate of Exemption from the Insurance Commissioner. I DO NOT employ anyone. I HAVE paid or otherwise compensated employees, therefore, I am furnishing the following information: Insurance Company Name: __________________________________________________________ Street Address: ___________________________________________________________________ City, State, Zip Code: ______________________________________________________________ Insurance Policy Number: ____________________________________ Date it Expires: _________ 8. 9. Does the pharmacy have all the required equipment listed in 6800.1050? Yes No If this application is for a ne
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