Vermont > Secretary Of State > Office Of Professional Regulation
Non-Resident Drug Outlet Change In Ownership Application - Vermont
| Non-Resident Drug Outlet Change In Ownership Application Form. This is a Vermont form and can be used in Office Of Professional Regulation Secretary Of State . |
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Vermont Secretary of State Office of Professional Regulation VERMONT BOARD OF PHARMACY National Life Building, North, FL 2 Montpelier, VT 05620-3402 Ph: (802) 828-2373 or 828-1505 Fax: (802) 828-2465 E-Mail: "kkemp@sec.state.vt.us" Web Site: www.vtprofessionals.org INSTRUCTION SHEET FOR NON-RESIDENT (OUT-OF-STATE) DRUG OUTLET (PHARMACY) You may contact Kristy Kemp, Administrative Assistant, at (802) 828-2373 or via E-mail: kkemp@sec.state.vt.us if you have questions or if you need additional information. Once your application is complete, it will be sent to the Board for review. The Board usually meets on the fourth Wednesday of each month. See the Board's Web site for specific meeting dates, agendas, minutes, etc. This application applies to out-of-state (Non-Resident) drug outlets or pharmacies. See Part 16 of the Board's Rules. http://vtprofessionals.org/opr1/pharmacists/rules.asp "Non-resident pharmacy" means a drug outlet located outside of this state which dispenses prescription drugs or devices to Vermont residents or residents of other states and which mails, ships, or delivers such prescription drugs or devices into this state or which provides any type of pharmacy services. All signatures required on the application must be those of an Owner, a Partner, or Corporate Officer. Non-Resident Pharmacies / Drug Outlets must submit the following: 1. 2. Completed application Application fee of $300.00. Please make your check payable to Vermont Secretary of State. Application fees are non-refundable. Verification of licensure standing directly from the licensing authority in the state where the pharmacy is located that will be shipping drugs to Vermont. No form is provided. Contact your state's Board of Pharmacy or applicable licensing authority and request that a verification of good standing be sent to Vermont. Note: Online verification is acceptable provided the state in which the facility is located reports whether disciplinary action(s) has been taken against the applicant. 3. 4. List(s) of the names of all owners. Indicate whether sole proprietor, partnership, corporation, limited liability company, etc. Note: Changes in ownership require submittal of a new application. Provide a flow chart showing ownership. If an actual flow chart is not available, a description of the ownership or hierarchy of the organization is acceptable. (See Board Rule 16.2 (c)) (1) If a person: the name, business address, and date of birth; (2) If a partnership: the name, business address, and date of birth of each partner, and the name of the partnership; (3) If a sole proprietorship: the full name, business address, social security number, and date of birth of the sole proprietor and the name of the business entity; and (4) If a corporation: the federal identification number of the corporation, the name, business address, date of birth, and title of each corporate officer and director, the corporate names, the name of the state of incorporation, and the name of the parent company, if any; the name, business address of each shareholder owning five percent or more of the voting stock of the corporation, including over-thecounter stock, unless the stock is traded on a major stock exchange and not over-the-counter; American LegalNet, Inc. www.FormsWorkFlow.com 5. Affirmation Forms completed by the sole proprietor, all members, all partners, or corporate officers and directors, and the pharmacist-manager, that they have not been convicted of, and are not under indictment for, any felony or misdemeanor arising from the violation of any drug or pharmacy related law. Questions must be answered and your signature must be notarized. (Rule 16.2) 6. Required Statement(s). The Pharmacist Manager may sign the form provided with this application regarding the required statements or may make the statements on pharmacy letterhead. A copy of the prescription label with toll free number may be applied to this statement or attached separately. (See Board Rule 16.2 (e) (f) and (g)). 7. A copy of the most recent inspection report from the state in which the pharmacy is located; and Effective July 1, 2010: For internet non-resident pharmacies, a copy of an inspection report not more than three years old by either: (1) the state in which the pharmacy is located; or (2) Verified Internet Pharmacy Practice Sites (VIPPS) certification. Where the Pharmacy Board in the other state has not inspected the pharmacy in the past three years through no fault of the pharmacy, the pharmacy may advise this Board of the inspection delay and this Board may grant the pharmacy an extension of up to one year to allow the pharmacy to comply with this rule. 8. Disciplinary Actions or Denials: Answers to these questions pertain to the applicant, its parent, subsidiaries, or another person or organization with a controlling interest in the drug outlet. If the answer is "yes" on the application form, provide certified copies of the charges, if filed, and of the Final Disposition Order. In addition, a signed and sworn statement from the CEO, COO, president or equivalent management level corporate officer showing how the company has responded to the prior violation such that the Vermont Board of Pharmacy can be assured that a repeat or similar violation will not occur in Vermont. Please also ask the state in which the action was taken to provide to the Board verification of current licensure standing. An Investigative Team will review this information to determine whether further investigation or action is needed before a final decision is made regarding your application. If your Internet Pharmacy is certified by the National Association of Boards of Pharmacy's Verified Internet Pharmacy Practice Sites (VIPPS) program, please provide a copy of your certification. For more information contact the NABP via www.nabp.net. NOTE: All licensees renew on a fixed 24 month schedule: July 31 (odd numbered years). Applicants issued an initial license more than 90 days prior to the renewal date will be required to renew and pay the renewal fee. Initial licenses issued within 90 days of the renewal date will not be required to renew or pay the renewal fee. The Statutes and Rules are available via the Board's Web site at: http://vtprofessionals.org/opr1/pharmacists/rules.asp www.vtprofessionals.org American LegalNet, Inc. www.FormsWorkFlow.com Vermont Secretary of State Office of Professional Regulation National Life Building, North FL 2 Montpelier VT 0562
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