Fingerprint Form For Pharmacy Permit Under Chapter 465 Florida Statutes
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Fingerprint Form For Pharmacy Permit Under Chapter 465 Florida Statutes Form. This is a Florida form and can be use in Department Of Health Statewide.
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FINGERPRINT FORM FOR A PHARMACY PERMIT UNDER
CHAPTER 465, FLORIDA STATUTES
GENERAL INSTRUCTIONS: TYPE OR PRINT LEGIBLY. Please attach this form to each fingerprint card when
submitting the card to the Board. The form must contain the personal information of person whose fingerprint
card is attached.
Application for: ______________________________________________________________________________
Name of Pharmacy
__________________________________________________________________________________________
Address of Pharmacy
________________________________
If applicable, current Florida Permit Number
1. PERSONAL INFORMATION:
Last Name
First Name
Middle Name
Alias (Nicknames, Maiden Name, Other Name Changes: legal or otherwise)
Present Residence Address (Street & Apt #)
City
State & Zip Code
Residence Telephone No.
Date of Birth
Place of Birth (City, County, State, Country)
I certify that the information on this form is true, complete, and correct and I do authorize the Florida Board of Pharmacy to
make any investigations that they deem appropriate and to secure any additional information concerning me. I understand
that providing false information may result in disciplinary action against my license or criminal penalties pursuant to sections
465.016, 775.082, 775.083, and 775.084, F.S.
__________________________
Signature
1
DH-MQA 1236, 5/10
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