WEST VIRGINIA BOARD OF PHARMACY 232 Capitol Street Charleston, West Virginia 25301

APPLICATION FOR PERMIT OR RENEWAL TO OPERATE AS A WHOLESALE DRUG DISTRIBUTOR July 1, 2005 to June 30, 2006

Current name and address

LICENSE #

DEA #

PHONE #

Any person, firm, corporation or partnership engaging in the wholesale distribution of human prescription drugs shall be subject to the WHOLESALE DRUG DISTRIBUTION LICENSING ACT of 1991, Chapter 60A, Article 8 of the Code of West Virginia, as amended.

Doing Business As:

Individual ____

Partnership ____

Corporation ____

Name of Manager-In-Charge

List current owner, partners, or corporate officers and titles

List other state(s) of licensure:

1. _____

2. _____

3. _____

4. _____

5. _____

6. _____

7. _____

8. _____

9. _____

Have your premises been inspected for safeguards relative to the Act? ________

TO THE BEST OF YOUR KNOWLEDGE

Has anyone connected with the firm ever been convicted of a felony? _______ If so, attach a detailed statement.

Are any registered pharmacists employed? ________ If yes, list name(s) below.

AFFIDAVIT:

I DO SOLEMNLY SWEAR AND AFFIRM THAT I AM THE AUTHORIZED PERSON TO SIGN FOR THIS APPLICATION FOR LICENSURE AND ALL STATEMENTS MADE ARE TRUE AND CORRECT.

NOTE: A FEE OF $400.00 MUST BE ENCLOSED. ALL FEES ARE NON-REFUNDABLE.

IF YOU ARE LOCATED OUTSIDE THE STATE OF WEST VIRGINIA, YOU MUST ATTACH A COPY OF YOUR STATE LICENSE AND COPIES OF YOUR FEDERAL AND STATE CONTROLLED SUBSTANCE REGISTRATION, IF SHIPPING CONTROLLED SUBSTANCES.

SIGNATURE

TITLE