THE STATE EDUCATION DEPARTMENT / THE UNIVERSITY OF THE STATE OF NEW YORK / ALBANY, NY 12234 NEW YORK STATE BOARD OF PHARMACY, Lawrence H. Mokhiber, Executive Secretary 89 Washington Avenue, 2nd Floor, Albany, NY 12234-1000 Tel. (518) 474-3817, ext. 130 Fax (518) 473-6995 E-mail: pharmbd@mail.nysed.gov Web: www.op.nysed.gov Pharmacy / Wholesale Distributor / Manufacturer License Verification This Affidavit must be completed by the State licensing authority in which the holder of the license/permit resides. Please return this completed affidavit to the applicant so that it may accompany the request for registration with the New York State Board of Pharmacy. This is to verify that: Name of Applicant_____________________________________________________ Address______________________________________________________________ _______________________________________________________________ License/Permit Number____________________________ Effective Date Expiration Date ____________________________ _____________________________ Authorized to do business as: Please check one: Pharmacy Wholesaler Distributor Manufacturer In the State of ______________________________________ This is to further verify that the above-named license/permit is current and in good standing. ______________________________________________________ Complete Name of Licensing Agency ______________________________________________________ Signature _________________________________________________________________ Contact Person Phone Number Imprinted Official State ____________________________________________ Date Seal OOS-506 (10-2007) American LegalNet, Inc. www.FormsWorkFlow.com