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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 OF A PHARMACY |
| July 1,
2004 to June 30,
2005 | |
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1. CURRENT NAME OF
BUSINESS TO BE LICENSED BY THIS PERMIT: |
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LICENSE # |
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COUNTY |
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DEA # |
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PHONE
# |
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2. PHARMACIST IN
CHARGE |
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RPh # |
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a. Has your Pharmacist
License ever been denied, suspended, or revoked in this or any other
state? |
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Yes ___ No
___ |
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b. Have you ever been
convicted of a felony? |
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Yes ___ No
___ |
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c. Have you ever been
convicted of a misdemeanor other than a traffic violation? |
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Yes ___ No
___ |
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d. Do you ever work
partime in any other pharmacy? |
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Yes ___ No
___ |
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If any answer in #2 is
Yes, attach a detailed explanation. |
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3. RENEWAL FEES. Circle
All Applicable a. through e.: |
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a. PHARMACY -
Inpatient |
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$100.00 |
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b. PHARMACY -
Outpatient |
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$100.00 |
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c. CONTROLLED SUBSTANCE
PERMIT |
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$10.00 |
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d. STERILE
PHARMACEUTICAL COMPOUNDING PERMIT |
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$100.00 |
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e. NUCLEAR
PHARMACY |
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$100.00 |
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Name of
Enteral/Parenteral Pharmacist Manager |
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RPh # |
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ATTACH CHECK OR MONEY
ORDER TO APPLICATION |
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TOTAL FEES
$___________ |
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4. CIRCLE APPLICABLE
DRUG SCHEDULES: |
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| II III IV V
NARCOTIC |
| II III IV V
NON-NARCOTIC | |
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5. CIRCLE TYPE OF
OWNERSHIP |
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SINGLE PROPRIETOR
PARTNERSHIP CORPORATION |
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6. NAMES OF PRINCIPLES
AND TITLES: (Owner; Partners; Three Corporate Officers) |
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7. Has the applicant or
any officer or partner of the applicant ever been convicted of a
Felony? |
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8. The
undersigned hereby swear, or affirm, that all statements made herein are
true and correct, and that all provisions of the law and regulations
relative to the practice of pharmacy, will be faithfully observed so long
as any permit issue will be in force. |
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9.
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Signature of Applicant,
Managing Partner or Office |
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Title |
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Date |
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10. |
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Signature of Pharmacist
in Charge |
RPh # |
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Date |
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