|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| |
| |
| |
|
| WEST VIRGINIA BOARD OF PHARMACY |
| 232 Capitol Street |
| Charleston, West Virginia 25301
| |
|
|
|
|
| APPLICATION FOR LICENSE PERMIT OR RENEWAL AS A
MANUFACTURER
|
| July 1, 2005 to June 30, 2006 |
|
|
|
| |
|
Current name and
address |
| |
| |
| |
| |
| |
|
LICENSE # |
|
DEA # |
|
PHONE
# |
| |
|
Type of
Manufacturer: |
|
Individual
____ |
|
Partnership
____ |
|
Corporation
____ |
|
List current owner,
partners, or corporate officers and titles |
| |
| |
| |
| |
| |
|
List Products to be
manufactured, packaged or repackaged: |
| |
| |
| |
| |
| |
|
Pharmacist in
Charge |
|
RPH # |
|
Phone |
|
Address |
|
City |
|
State |
|
Zip |
|
County |
|
NOTE: If a pharmacist
is not employed, give the following information on person in
charge: |
|
Person in
Charge |
|
Phone |
|
Address |
|
City |
|
State |
|
Zip |
|
County |
|
I hereby
certify that the answers given in this application are true and correct to
the best of my knowledge. I understand that approval of this application
will only extend to those products listed and that the products and
personnel approved thereby are not subject to change except on approval by
the Board of Pharmacy of a new application. |
|
|
| |
|
NOTE:
THE FEE FOR A PERMIT IS $500.00 AND MUST ACCOMPANY ANY
APPLICATION |
| |
|
|
|
|
Signature
of Authorized Individual and
Title |