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| WEST VIRGINIA BOARD OF PHARMACY |
| 232 Capitol Street |
| Charleston, West Virginia 25301
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| APPLICATION FOR LICENSE PERMIT OR RENEWAL TO OPERATE A
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| MAIL ORDER PHARMACY |
| July 1, 2005 to June 30, 2006 |
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Current
name and address |
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LICENSE
# |
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DEA
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PHONE # |
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Every mail-order house which dispenses drugs or medicines through
the United States mail or otherwise from any point outside of the State of
West Virginia to any point within the State of West Virginia shall, as a
condition precedent to being qualified and authorized to transact such
business in the State of West Virginia, annually register with the Board
of Pharmacy to conduct such business in the State as provided for in
Chapter 30, Article 5, Section 6a(b) of the Code of West
Virginia. |
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Doing Business
As: |
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Individual
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Partnership
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Corporation
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Name of
Manager-In-Charge |
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List current
owner, partners, or corporate officers and titles |
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Name of
person authorized to sign for controlled substances |
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Registered
Pharmacist in Charge |
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Certificate
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State |
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List
Registered Pharmacists employed: |
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Have there
been any violations of pharmacy laws pertaining to any employee? ______ If
yes, detail by attachment. |
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The
undersigned hereby swears, or affirms, that all statements made herein are
true and correct, and that all the provisions of the law and regulations
based thereon, relative to the practice of pharmacy, will be faithfully
observed during the period any permit issued may be in force and
effect. |
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Every initial application for a permit shall be accompanied by the
required fee of $500.00. The renewal of such permit or license shall be
$500.00 ANNUALLY. You must attach copies of your State License and most
current inspection report.
_______________________________________________
___________________________________________________________ |
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SIGNATURE |
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SIGNATURE |
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(Owner, Partner, Corporate Officer) |
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(Pharmacist in Charge) |