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| WEST VIRGINIA BOARD OF PHARMACY |
| 232 Capitol Street |
| Charleston, West Virginia 25301
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| APPLICATION FOR PERMIT OR RENEWAL TO HANDLE CONTROLLED
SUBSTANCES
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| July 1, 2005 to June 30, 2006 |
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1. NAME, STREET
ADDRESS, & MAILING ADDRESS OF FACILITY NEEDING
PERMIT: |
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2. LICENSE # |
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DEA # |
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PHONE
# |
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COUNTY: |
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3. NAME OF OWNER OF
THIS FACILITY OR RESEARCHER APPLYING FOR PERMIT: |
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4. NAME AND REG. # OF
YOUR CONSULTANT PHARMACIST (If a., b., or c. in #7 Below): |
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5. PHONE NUMBER OF
CONSULTANT PHARMACIST |
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6. NAME AND DEA# OF
YOUR REGISTRANT (If f in #7 Below): |
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7. PLEASE SHOW TYPE OF
FACILITY BY CIRCLING APPLICABLE LETTERS "A" THROUGH "E": |
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a. Hospital or Clinic
(without pharmacy) |
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$50.00 |
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b. Jail or
Prison |
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$25.00 |
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c. Extended Care
Facility or Nursing Home |
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$25.00 |
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d. Researcher (exempt
from fee if STATE employee |
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$25.00 |
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e. Government Official
(exempt from fee) |
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$0.00 |
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f. Humane Society or
Ambulance Service |
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$25.00 |
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ATTACH CHECK OR MONEY
ORDER TO APPLICATION |
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TOTAL FEES
$___________ |
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| 8. CIRCLE
APPLICABLE DRUG SCHEDULES: |
| (Schedule I for
Researchers Only) | |
| II III IV V
NARCOTIC |
| II III IV V
NON-NARCOTIC | |
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9. NAME & ADDRESS
OF PERSON WITH CONTROLLED SUBSTANCE POWER OF ATTORNEY: |
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10. PLEASE SHOW TYPE OF
BUSINESS OWNERSHIP BY CIRCLING APPLICABLE "A" THROUGH "G". |
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A. SINGLE
PROPRIETOR |
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B. PARTNERSHIP |
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C. CORPORATION |
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D.
RESEARCHER |
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E. SINGLE
PROFESSIONAL |
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F. PROFESSIONAL
GROUP |
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G. OTHER (DESCRIBE ON
REVERSE) |
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11. OWNER; SENIOR
PARTNERS; THREE CORPORATE OFFICERS; RESEARCHER & DEPARTMENTNT
HEAD: |
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12. Has the owner,
researcher, any partner or any officer ever been convicted of a Felony?
Yes ___ No ___ (If yes, attach a detailed statement) |
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13. |
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____________________________________________ |
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_______________ |
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______________ |
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Signature of Applicant,
Partner, Officer, Researcher |
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Title |
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Date |
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14. |
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____________________________________________ |
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_____________________________ |
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______________ |
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Signature of Pharmacist
Consultant or DEA Registrant |
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DEA or RPh # |
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Date |
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