BOARD OF PHARMACY New Mexico Regulation and Licensing Department BOARDS AND COMMISSIONS DI VISI ON 5 20 0 Oak l a n d Av e n u e, N E ▪ S uit e A ▪ Al b u q u er q u e, N e w M ex i c o 87 1 1 3 (5 0 5 ) 2 2 2 -9 8 3 0 ▪ F a x ( 5 0 5) 2 2 2- 9 8 4 5 ▪ ( 8 0 0) 5 6 5- 91 0 2 w ww. R LD . st a t e. n m. u s/ p h a r ma c y www.rld.state.nm.us/pharmacy Sarah.Trujillo@state.nm.us NONRESIDENT PHARMACY APPLICATION FEE: $400.00 Biennial (Please pay by check or money order) Applications and fees must accompany each; otherwise processing time will be delayed. Retain a copy of both the application and form of payment for future reference. Mail early-5-10 days processing time once application is received NAME & MAILING ADDRESS: __________________________________ __________________________________ __________________________________ PHONE NO:________________________ EMAIL: ____________________________ NAME & STREET ADDRESS: __________________________________ __________________________________ ___________________________________ FAX NO: _____________________________ WEB ADDRESS ______________________ REQUIRED TOLL FREE NUMBER FOR NEW MEXICO RESIDENTS: ______________________________ ( )NEW; ( ) CHANGE OF OWNERSHIP current license number PH________ I, the undersigned, hereby apply for a license to operate a Pharmacy under the Pharmacy Laws of the State of New Mexico and present the following statements in support of the privilege to be granted a license and represent that if such license is granted, such place will be conducted in full compliance with existing Pharmacy laws, and rules and regulations of the Board of Pharmacy unless compliance would violate the laws and regulations of the resident state. I (we) hereby understand that the license expires December 31 of every other year, that the license is not transferable, and that a separate license is required for each pharmacy location. Renewal applications must be returned or postmarked by December 31. You must include an additional $100.00 (the late penalty) if postmarked after December 31. Enter current registration numbers; "pending" if applying for; or "N/A" (not applicable). 1. Federal DEA Reg. No._______________________ *New Mexico Controlled Substance Registration No.________________________ Resident State Controlled Substance Registration No.______________________ *A New Mexico Controlled Substance license is required for shipping/mailing controlled substances into New Mexico. PLEASE CIRCLE LETTER BESIDE APPROPRIATE CLASSIFICATION: 2. a. If individual is owner, give name and address; b. If a partnership is owner, give name and address of all partners, (attach list); c. If a corporation or municipality, list name, address and title of all officers, (attach list); d. If county, city, state or church is owner, give name, address and title of all officers, (list); NAME(S) TITLE HOME ADDRESS CITY STATE ZIP ___________________________________________________________________________________ ___________________________________________________________________________________ 3. Attach copy of current resident state license, permit or registration to operate a pharmacy. Revision date: 10/2009 American LegalNet, Inc. www.FormsWorkFlow.com Board of Pharmacy 4. Attach a copy of the most recent inspection conducted by the resident state regulatory or licensing agency. 5. All applicants submit a policy & procedure manual as required by the New Mexico Board of Pharmacy Rules & Regulations. The policy and procedures manual as defined in 16 NMAC 19.6.24.C1(d) & D(2). This manual will have the following policies: DO NOT SEND ENTIRE POLICY MANUAL, ONLY THE FOUR ITEMS LISTED BELOW A. Normal delivery protocols and times; B. The procedures to be followed if the patient's medication is not available at the Nonresident Pharmacy, or it the delivery will be delayed beyond the normal delivery time; C. The procedure to be followed upon receipt of a prescription for an acute illness, which policy shall include a procedure for delivery of the medication to the patient from the Nonresident Pharmacy at the earliest possible time (i.e. courier delivery), or an alternative that assures the patient the opportunity to obtain the medication at the earliest possible time; D. The procedure to be followed when the Nonresident Pharmacy is advised that the patient's medication has not been received within the normal delivery time and that the patient requires interim dosage until mailed prescription drugs become available. 6. Give the name and address of a resident agent in New Mexico for service of process. NAME(S) TITLE NEW MEXICO ADDRESS CITY ZIP PHONE ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ 7. List all other states where licensed, license number and expiration date. (attach list) 8. Attach a letter describing in detail the nature of your business in the State of New Mexico. 9. List all trade or business names ("DBA" names) previously or currently used by same corporation or by licensee: ______________________________________________________________________________ 10. We have not been arrested, investigated for, charged with, convicted of, sentenced, entered a plea of non contendere, or entered into any other legal agreements for any criminal offense in any state, territory or possession of the United States or by the federal government.* Signature________________________________________________ 11. We do not have any disciplinary actions, or any pending actions against me/the pharmacy, or to my knowledge been investigated by any professional licensing authority.* Signature________________________________________________ *Please explain any failure to sign the statements above. Explain the circumstances, include a copy of the judgment, and attach to this application. I (we) hereby certify that the information given in this application is true and correct to the best of my (our) knowledge. ___________________________________________________________________________________ Signature Print Name & Title - Owner or Officer Date signed ___________________________________________________________________________________ Signature Print Name of Pharm-in-Charge License # Date signed New Mexico Regulation and Licensing Department BOARDS AND COMMISSION DIVISION Page 2 of 2 Revision date: 10/2009 American LegalNet, Inc. www.FormsWorkFlow.com