INSTRUCTION FOR COMPLETING THE APPLICATION FOR NON-RESIDENT PHARMACY REGISTRATION Please read carefully and follow all instructions. Incomplete applications delay the registration process. The application must be typed or legibly printed. All questions must be answered. If the question does not apply, write N/A. If the answer is not known, write unknown. If ownership is a partnership, corporation, or other, the additional information must be attached. Refer to the application for the documentation required. The address of the pharmacy must be the physical location, not post office boxes. The board office must be in receipt of a completed application and the fee before the application will be processed. Enclose a copy of your DEA certificate if you are registered to dispense controlled substances. Enclose a license verification from your home-state stating that your pharmacy is actively licensed and in good standing with that Board and a copy of your home state pharmacy registration. Signatures are required for the owner and the pharmacist-in-charge. If the owner and PIC are the same individual, both portions must be signed and notarized. Application must be accompanied with a check or money order in the amount of $140.00. All registrations will expire on June 30 of each year and such registration will be canceled if not renewed annually by July 31st. The $140.00 fee is not prorated. The application and fee, along with any supporting documents should be sent to the address at the top of the application. CHECKLIST: _____ (1) Application completed, including two (2) signatures and notaries? _____ (2) Copy of corporate officers or other documentation enclosed? _____ (3) Check or money order in the amount of $140.00 enclosed? _____ (4) Copy of DEA certificate enclosed? _____ (5) License Verification from Home State enclosed? _____ (6) Copy of Home State Pharmacy Registration enclosed? _____ (7) Copy of most recent Home State inspection report enclosed? Pg. 1 of 6 American LegalNet, Inc. www.FormsWorkFlow.com NON-RESIDENT PHARMACY REGISTRATIONS The following circumstances require applying for a new non-resident pharmacy permit. NEW PHARMACY: A pharmacy registration is required prior to doing business as a pharmacy in the State of Kansas. CHANGE OF ADDRESS: A non-resident pharmacy currently registered with the Board of Pharmacy may not continue to ship into the state from their new address without prior approval from the Board. This approval is obtained through the issuance of a new non-resident pharmacy registration. It is recommended that an application be made for the new location approximately one month in advance. CHANGE OF OWNER: A new non-resident pharmacy registration is required when there is a 50% or more change in controlling interest. An application must be made to the Board office by the new ownership. It is recommended that an application be made approximately one month in advance of the ownership change. Within 5 days of the change date, the previous registration should be returned to the Board office. If the ownership change is less then 50%, notification must be made to the Board office in writing of the change of ownership, but does not require a new registration. CHANGE IN PHARMACIST-IN-CHARGE: A two week written resignation notice is required to be given to the owner and a copy sent the Board office. A new application changing the PIC needs to be initiated with the Board office so the new PIC can effectively be in place within 30 days of the resignation of the former PIC. Pg. 2 of 6 American LegalNet, Inc. www.FormsWorkFlow.com FOR OFFICE USE ONLY KANSAS STATE BOARD OF PHARMACY 800 SW JACKSON, ROOM 1414 TOPEKA, KS 66612 (785) 296-4056 FAX (785) 296-8420 REG NUMBER: ____________ DATE: ____________________ FEE $112.00 Check#_____________$__ APPLICATION FOR NON-RESIDENT PHARMACY REGISTRATION This application is being made for the following reason: (check all that apply): ______New Pharmacy ______Change of Address ______Change of Ownership ______Change of PIC If a Change of Address: Previous License Number (if applicable)________________ Or Previous Address__________________________________________________________________ The owner hereby makes application as follows: ______________________________________________________________________________________ BUSINESS NAME OF OWNER ______________________________________________________________________________________ ADDRESS OF OWNER ______________________________________________________________________________________ CITY STATE ZIP PHONE NUMBER ______________________________________________________________________________________ E-MAIL ADDRESS Type of ownership: ____Individual ____Partnership ____Corporation _____Other IF PARTNERSHIP, attach additional listing of names and percentage of ownership. IF CORPORATION, attach additional officer and owners of stock. IF OTHER, attach additional sheet indicating the type of ownership. Type of Pharmacy: ______Renal Dialysis ______Retail Chain ______Retail Community ______Hospital/Institution ____Ambulatory Surgery Center _____ Other __________________________ The owner makes application to establish and maintain a pharmacy under the name of and at the location as follows: ______________________________________________________________________________________ NAME OF PHARMACY ______________________________________________________________________________________ PHYSICAL ADDRESS OF PHARMACY ______________________________________________________________________________________ CITY STATE ZIP TOLL FREE TELEPHONE NO. ______________________________________________________________________________________ E-MAIL ADDRESS WEB SITE ADDRESS Pg. 3 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Does your pharmacy have a web site? ____Yes ____No If so are patients able to purchase prescriptions on it? ____Yes _____No DESIGNATED RESIDENT AGENT: _______________________________________________________ NAME ADDRESS PHONE Designated resident agent defaults to the Secretary of State. To use the default ­ check here _____ Hours pharmacy is open _________________ to _______________ Hours store / facility is open ______________to _____________ Total hours per week a pharmacist will be held on duty in facility_____________________________ The above named owner places the following licensed pharmacist as pharmacist-in-charge of the pharmacy indicated above: ____________________________________________