WEST VIRGINIA BOARD OF PHARMACY
232 Capitol Street
Charleston, West Virginia 25301
APPLICATION FOR LICENSE PERMIT OR RENEWAL TO OPERATE A
MAIL ORDER PHARMACY
July 1, 2005 to June 30, 2006
 
Current name and address
 
 
 
 
 
LICENSE # DEA # PHONE #
 
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.
Doing Business As: Individual ____ Partnership ____ Corporation ____
Name of Manager-In-Charge
List current owner, partners, or corporate officers and titles
 
 
 
 
 
 
Name of person authorized to sign for controlled substances
Registered Pharmacist in Charge Certificate # State
List Registered Pharmacists employed:
 
 
 
 
 
 
 
 
Have there been any violations of pharmacy laws pertaining to any employee? ______ If yes, detail by attachment.
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.
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 SIGNATURE
(Owner, Partner, Corporate Officer) (Pharmacist in Charge)