Lawrence H. Mokhiber Executive Secretary The University of the State of New York THE STATE EDUCATION DEPARTMENT Office of the Professions New York State Board of Pharmacy 89 Washington Avenue Albany, NY 12234-1000 Phone: 518-474-3817 ext. 130 E-mail: pharmbd@mail.nysed.gov Department Use Only APPLICATION FOR INITIAL REGISTRATION OR TRANSFER OF OWNERSHIP OF PHARMACY PLEASE PRINT LEGIBLY OR TYPE 1 P1 $345 IR Registration Number: _____________ Name under which registration is sought Registered as of: ____ / ____ / ____ Approved: _____________________ Date: ____ / ____ / ____ 2 Address Street and Number City State County Zip Code 3 If a transfer of ownership, under what name is this establishment currently registered? Registration number: __________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________ Date of proposed transfer: ________ / _______ / ________ 4 Trade name or assumed name of firm, if any. (Only assumed names registered with the County Clerk or New York State Department of State are acceptable). _______________________________________________________________________________________________________________________ 5 (a) Please indicate type of ownership: (b) County ________________________________ Individual (c) Telephone _____________________________ Government Owned LLC not-for-profit (d) Fax ___________________________________ Corporation for profit Partnership/LLP for profit (e) E-mail _________________________________ Corporation not-for-profit 6 LLC for profit Partnership/LLP not-for-profit (f) Federal Employer. ID# ____________________ Name the supervising pharmacist who will be responsible for the supervision of the activities to be conducted by the registrant. Name of supervising pharmacist _____________________________________________________________________________________ Pharmacist License number __________________________ 7 Date of licensure ________ / ________ / ________ Contact person to clarify information provided on this application: Name: __________________________________________________________________________________________________________________ Phone: ______________________________________________________ Fax: ______________________________________________________ E-mail address: __________________________________________________________________________________________________________ Form PH 200, Page 1 of 4, (Rev. 9/08) American LegalNet, Inc. www.FormsWorkFlow.com 8 Names of ALL pharmacists including the supervising pharmacist, and of pharmacy interns, as printed on original licenses, or permits, practicing in this pharmacy. (Use additional sheets if necessary.) 9 Social Security Number Hours worked each week Pharmacist License No. or Permit No. Original date of issue Check all that apply: Is this location also registered as a: If yes, pharmacy manufacturer wholesaler repacker Name: __________________________________________________________________ Registration number: _____________________ Does the applicant, individual owner, partner, officer or principal stockholder have financial or ownership interest in any New York State registered: pharmacy manufacturer wholesaler repacker If yes, list any/all registered pharmacy/manufacturer/wholesaler/repacker that the applicant, individual owner, partner, officer or principal stockholder has interest in. (Attach a list if necessary.) ________________________________________________________________________________ Registration number: _____________________ ________________________________________________________________________________ Registration number: _____________________ ________________________________________________________________________________ Registration number: _____________________ 10 (a) How many hours per week is this establishment open for business? _____________________________________________________________ (b) How many hours per week does the supervising pharmacist work at this establishment? _____________________________________________ 11 Has the applicant, or any individual owner or partner in a partnership, or any officer, director or principle stockholder in a corporation ever been known by any other name(s)? YES NO If Yes, indicate such former name or names and reason for changing. _______________________________________________________________ _______________________________________________________________________________________________________________________ 12 MORAL CHARACTER The following questions pertain to any owner or corporate officer of the establishment or registrant. (a) Have you ever been found guilty after trial, or pleaded guilty, no contest, or nolo contendere to a crime (felony or misdemeanor) in any court? YES NO (b) Are criminal charges pending against you in any court? YES NO (c) Has any licensing or disciplinary authority refused to issue you a license or ever revoked, annulled, cancelled, accepted surrender of, suspended, placed on probation, refused to renew a professional license or certificate held by you now or previously, or ever fined, censured, reprimanded or otherwise disciplined you? YES NO (d) Are charges pending against you in any jurisdiction for any sort of professional misconduct? YES NO (e) Have you ever willfully failed to provide records to any State Licensing authority or to Federal, State or Local law enforcement officials that are required by Federal, State or Local laws? YES NO YES NO If yes, please explain __________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ (f) Has any hospital or licensed facility restricted or terminated your professional training, employment, or privileges or have you ever voluntarily or involuntarily resigned or withdrawn from such association to avoid imposition of such measures ? NOTE: If you answer “Yes” to any questions (a) through (f), submit a letter giving complete explanation. Include copies of any court records, and if you possess one, a copy of the “Certificate of Relief from Disabilities” or your “Certificate of Good Conduct.” Form PH 200, Page 2 of 4, (Rev. 9/08) American LegalNet, Inc. www.FormsWorkFlow.com 13 Give full name and requested information for each corporate officer, partner or member. Check the box of the newest officer. USE ADDITIONAL SHEETS IF NECESSARY. Title ___________________________________________________________ Last four digits of their Social Security Number: Full name ___________________________________________________________________________________________________________ Home address (street/city/state/zip) _______________________________________________________________________________________ ____________________________________________________________________________________________________________________ Home telephone number: ____________________________ Licensed Pharmacist? YES NO License # _____________________ Title ___________________________________________________________ Last four digits of their Social Security Number: Full name ___________________________________________________________________________________________________________ Home address (street/city/state/zip) _______________________________________________________________________________________ ____________________________________________________________________________________________________________________ Home telephone number: ____________________________ Licensed Pharmacist? YES NO License # _____________________ Title ___________________________________________________________ Last four digits of their Social Security Number: Full name ___________________________________________________________________________________________________________ Home address (street/city/state/zip) _______________________________________________________________________________________ ____________________________________________________________________________________________________________________ Home telephone number: ____________________________ Licensed Pharmacist? YES NO License # _____________________ Title ___________________________________________________________ Last four digits of their Social Security Number: Full name ___________________________________________________________________________________________________________ Home address (street/city/state/zip) _______________________________________________________________________________________ ____________________________________________________________________________________________________________________ Home telephone number: ____________________________ 14 Licensed Pharmacist? YES NO License # _____________________ a. Give full name and requested information for each owner or principle stockholder (owning 10% or more of corporate stock). Check the box of the newest owner or stockholder. USE ADDITIONAL SHEETS IF NECESSARY. b. Is this a public owned corporation? YES NO. c. Not-for-Profit entity DO NOT COMPLETE THIS SECTION. Full name ___________________________________________________________________________________________________________ Home address (street/city/state/zip) _______________________________________________________________________________________ ____________________________________________________________________________________________________________________ Home telephone number: __________________________________________ Last four digits of their Social Security Number: Licensed Pharmacist? YES NO License # __________________ # of shares owned __________ shares owned __________% Full name ___________________________________________________________________________________________________________ Home address (street/city/state/zip) _______________________________________________________________________________________ ____________________________________________________________________________________________________________________ Home telephone number: __________________________________________ Last four digits of their Social Security Number: Licensed Pharmacist? YES NO License # __________________ # of shares owned __________ shares owned __________% Full name ___________________________________________________________________________________________________________ Home address (street/city/state/zip) _______________________________________________________________________________________ ____________________________________________________________________________________________________________________ Home telephone number: __________________________________________ Last four digits of their Social Security Number: Licensed Pharmacist? YES NO License # __________________ # of shares owned __________ shares owned __________% Full name ___________________________________________________________________________________________________________ Home address (street/city/state/zip) _______________________________________________________________________________________ ____________________________________________________________________________________________________________________ Home telephone number: __________________________________________ Last four digits of their Social Security Number: Licensed Pharmacist? YES NO License # __________________ # of shares owned __________ shares owned __________% Form PH 200, Page 3 of 4, (Rev. 9/08) American LegalNet, Inc. www.FormsWorkFlow.com 15 ATTESTATION OF REGISTRANT The undersigned affirms under penalty of perjury that the answers and statements that he/she has made in the above application are true and have been made and given with the intent of having the New York State Education Department and the New York State Board of Pharmacy rely on the truth thereof. ________________________________________________________________________ ______________________________________________ (print name) (title) Signature of registrant ________________________________________________________ Date ________ / ________ / ________ (Individual Owner, Partner, Corporate Officer, Member or *Other Authorized Person) mo. day yr. *Power of attorney must be submitted. 16 ATTESTATION OF SUPERVISING PHARMACIST – PERSON NAMED IN ITEM 6 I hereby certify that I have full knowledge of my responsibilities and will discharge these responsibilities to the best of my ability and that I am not the supervising pharmacist of any other establishment registered by the Board of Pharmacy. _______________________________________________________________________________________________________________________ (print name) Signature of supervising pharmacist __________________________________________________________________________________________ Date ________ / ________ / ________ mo. day yr. To assure prompt filing, please be sure you have completed all portions of this APPLICATION and send it with a fee of $345 to: New York State Education Department Board of Pharmacy 89 Washington Avenue Albany, NY 12234-1000 Note: Please make check or money order payable to the “New York State Education Department”. Payments made outside the United States should be made payable by check or draft on a United States bank in U.S. currency. Form PH 200, Page 4 of 4, (Rev. 9/08) American LegalNet, Inc. www.FormsWorkFlow.com