Hospital Pharamacy Associated Clinics Form

Date Stamp Here Revenue: 0262010000 Fees(checkallthatapply) FWithout controlled substance.................... fee FWith controlled substance......................... fee All application fees are nonrefundable You can check the online fee page for current fees. Nonresident Pharmacy License Application This is for: F New F Change of Ownership F Change of Location--Current License # ______________ F Name Change Only--Current Facility Name _____________________________________________ Check One FAssociation FCorporation F Federal Government Agency FLimited Liability Company FLimited Liability Partnership F Limited Partnership F Municipality (City) F Municipality (County) F Non-ProfitCorporation F Partnership F SoleProprietor F StateGovernmentAgency F Tribal Government Agency FTrust 1. Demographic Information UBI# FederalTaxID(FEIN)# Legal Owner/Operator Name Mailing Address City State ZipCode County Phone (enter 10 digit #) Email Address Fax (enter 10 digit #) Web Address: Facility/Agency Name (Business name as advertised on signs or Web site) Physical Address City State ZipCode County Facility Phone (enter 10 digit #) Email Address: Mailing Address (If different than physical address) City State Fax (enter 10 digit #) ZipCode County American LegalNet, Inc. www.FormsWorkFlow.com DOH 690-255 December 2013 Page 1 of 3 2. Facility Information Type of Pharmacy F Community/Retail F Mail-Order Monday­Friday F Hospital F Nuclear Saturday F Jail F Parenteral F Long-term Care (LTC) F Internet F Compounding Sunday Holidays Pharmacy Hours (Indicate the hours the pharmacy will be open) Toll-free Phone Number (You must provide a toll-free number for your pharmacy to become licensed) Pharmacy Toll-free Number___________________________________ Date of last inspection (attach copy): ____________________________________ Drug Enforcement Administration (DEA) Registration # ______________________ Background Questions Yes No 1. Have any applicants, partners, or managers had a suspension, revocation, or restriction of a professional license? .........................................................................................................................FF If yes, list and explain on a separate sheet of paper. 2. Have any applicants, partners, or managers been found guilty of a drug or controlled substance violation? .................................................................................................................................FF If yes, list and explain on a separate sheet of paper. Pharmacist Consultant Name License Number Date of Appointment 3. Contact Information Contact Person Name Title Phone (enter 10 digit #) Phone (enter 10 digit #) Title Email Address Email Address Contact Person Name 4. Additional Information DateofIncorporation CorporateNumber StateofCorporation Legal Owner Information-attach additional completed pages if you need more space. Listnames,addresses,phonenumbers,andtitlesofcorporateofficers,partners,members,andmanagers. Name Address Phone (enter 10 digit #) Title DOH 690-255 December 2013 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 3 Previous Name of Legal Owner Previous Name of Facility Change of Ownership Information Previous Pharmacy License # Effective Date of Ownership Change List all Pharmacist­attach additional completed pages if you need more space. Name License # AgentofRecordinWashingtonStateforServiceofprocess(cannotusetheSecretaryofState'sOffice) Name of Agent of Record Address Phone (enter 10 digit #) WrittenExplanation Provide a written explanation of the method used to maintain readily retrievable records of sales of controlledsubstances,legenddrugs,andmedicaldevicestoindividualsinWashingtonState. Other States of License (list below) Signature I certify I have received, read, understood, and agree to comply with state law and rule regulating this licensing category. I also certify the information herein submitted is true to the best of my knowledge and belief. SignatureofOwner/AuthorizedRepresentativeofPharmacy Date Print Name Print Title DOH 690-255 December 2013 American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 3