Steven W. Schierholt, Esq. John R. Kasich Executive Director Governor 77 South High Street, 17th Floor, Columb us, Ohio 43215 T : (614 ) 466.414 3 | F : (614 ) 752.483 6 | new.license @pharmacy.ohio.go v | www. pharmacy.ohio.gov PHARMACY TERMINAL DISTRIBUTOR OF DANGEROUS DRUGS PLEASE TYPE OR PRINT LEGIBLY 1. LICENSE REQUEST Change New Proposed opening date or date of change NOTE: DO NOT APPLY MORE THAN 90 DAYS BEFORE PROPOSED DATE OF OPEN If change, g ive current TDDD License Number If change, select ALL that apply : Name Ownership Other, please specify 2. NAME OF BUSINESS BEING LICENSED - Name under which applicant will be doing business, address, phone number, and mail ing address if different than above. Business Name (i.e. reflecte d by signage/how you will answer the phone) County Street Address ( No P.O. Box ) City, State Zip Code Phone (include area code) Mailing Address, City, State, Zip Code (if different fro m above) Fa x (include area code) 3.NAME OF BUSINESS SERVICING THE ENTITY LISTED IN #2 - This is only applicable for nursing home/other institution contingency stock . Name as listed on the TDDD License TDDD License Number 4 .APPLICANT INTENDS DOING BUSINESS AS ( Select One ) - . Government Sole Proprietorship Corporation Partnership Limited Liability Company For State of Ohio Board of Pharmacy Use Only Control # Amt Received O ffice/Field Class BT Drug Category II III L TDDD License New # /Same # American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 7 Revised (/2/2017) 5 a. NAME OF GOVERNMENT AGENCY (if applicable) Name 5 b. CORPORATION INFORMATION, IF INCORPORATED - A copy of articles of incorporation and/or limited liability paper s must accompany this application. The following information may be contained in the incorporation papers usually . Leave blank if Government Agency Entity /Charter number Federal Tax ID or EIN Number State where incorporated 5 c. NAME OF OWNER(S); OR, IF INCORPORATED, NAME AND TITLE OF OFFICERS (If more than four , please include information on a separate piece of paper) Leave blank if Government Agency Name Title % of ownership Date of Birth or Social Security Number Name Title % of ownership Date of Birth or Social Security Number Name Title % of ownership Date of Birth or Social Security Number Name Title % of ownership Date of Birth or Social Security Number 6 . CATEGORY OF LI CENSE (Check only ONE) Application is hereby made for a license as a TERMINAL DISTRIBUTOR of Dangerous Drugs, as provided in Sections 4729.54, 4729.541, 4729.55, 4729.551 and 4729.552 of the Ohio Revised Code, as follows: CATEGORY II - $10 This licensee may possess, have custody or control of, and distribute prescription drugs (including medical oxygen and other medical grade gases) that are not controlled substances. CATEGORY III - $0.00 This licensee may possess, have custody or control of, and distribute prescription drugs, including controlled substances contained in Schedules II, III, IV, or V. The following category applies only to remote order entry, medication management therapy, and consulting- only pharmacies LIMITED CATEGORY II - $10 This licensee may not possess, have custody or control of, and distribute prescription drugs (including medical grade gases). A consulting, remote order, or medication therapy management statement will be completed as part of the license. Drug Enforceme nt Administration License Number ( for Category III only; if pending leave blank ): 7. INDIVIDUAL TO CONTACT REGARDING ABOVE LOCATION, BETWEEN 8 AM AND 5 PM WEEKDAYS - I ndividual to contact if there are questions regarding the application (must be the R esponsible Person or Designee) & the person who will receive your Ohio license. Name Title Phone (including area code) E - mail American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 7 Revised (/2017) 8. E - MAIL ADDRESS TO RECEIVE YOUR OHIO LICENSE(S). MUST BE THE RESPONSIBLE PERSON OR DESIGNEE . (Ohio Board of Pharmacy no longer mails licenses via postal mail). Name of the individual that will print the license E - mail of the individual that will print the license Phone (including area code) 9 .PROVIDE A DETAILED NARRATIVE DESCRIPTION OF THE TYPE OF BUSINESS ACTIVITIES (PLEASE BE SPECIFIC) THAT WILL BE CONDUCTED AT THIS LOCATION THAT REQUIRES THE APPLICANT TO BE ISSUED A TDDD LICENSE Indicate your HOURS OF OPERATION , WEB SITE ADDRESS , and TYPE OF BUSINESS YOU ARE CONDUCTING in Ohio. Refer to example questions below to assist with narrative. Narrative MUST BE PROVIDED or the application is considered incomplete. Examples: Do you serv ice patients, animals, or facilities? What type of pharmacy (hospital, retail pharmacy, specialty clinic, physician office, pharmacy servicing other institutions, etc.)? What type of prescription medications do you dispense (specialty or retail)? Do you c ompound sterile and/or non - sterile products? American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 7 Revised (/2017)10.TYPE OF ESTABLISHMENT BEING LICENSED (Check ALL applies in this section) Retail Independent /Chain Nuclear Pharmacy Durable Medical Equipment Pharmacy (DME) Mail Order Pharmacy Mult i - Disciplinary Pharmacy (i.e. Multi - practice such as central fill, compounding, consulting, & mail order ) Other: Compounding Sterile Non - Sterile Fluid Therap y/Infusion Pharmacy Charitable Pharmacy Pharmacy Supplied Contingency Stock Correctional Institution Hospital Pharmacy - Servicing Others (i.e. Nursing Homes) 11 . APPLICANT LEGAL AND DISCIPLINARY QUESTI ONS Failure to answer the following questions makes your application incomplete, delaying the licensing process. Answering incorrectly could be a violation of Ohio law, see ORC 4729.57 and 2921.13 . Please note th at Applicant includes all the following ( when applicable) : T he b usiness e ntity O wner O perator Corporate o fficer s, including: p resident, vice president, secretary, treasurer, CEO, CFO, or any equivalent position Partner(s) S ole p roprietor Employees responsible for the provision of patient care a t the facility (this includes contract prescribers and other healthcare professionals) Any other person with access to drug stock* *Access to drug stock includes not only physical access, but also any influence over the handling of prescription drugs (i.e . dangerous drugs) such as purchases, inventories, issuance of medical orders, etc. It does not include employees/contractors such as maintenance, janitorial, IT or other staff that may need limited supervised access to areas where prescription drugs or D .E.A. controlled substance order forms are kept. For more information on answering the legal/disciplinary questions, visit: www.pharmacy.ohio.gov/legalquestions ** If the answer to any of the fo llowing questions a detailed account (including date, place, circumstances, and disposition of the matter) , and copies of relevant documents (such as court pleadings or orders, or other age ncy orders/dispositions)** 11 a. Has the applicant ever been convicted of, or are there charges pending for, a felony or misdemeanor drug offense under state or federal law? This includes a court granting intervention in lieu of treatment (also known as treatment in lieu of conviction, ILC or TLC), or other diversion programs. Felony or misdemeanor drug offenses must be included regardless of whether the case has been expunged or sealed or the equivalent thereof. This applies to question 11 a only . Note: Minor misdemeanor drug convictions are not required to be reported. ORC 2925.11(D). Yes No 11 b. Has the applicant ever been convicted of, or are there charges pending for, any other felony under state or federal l aw? Yes No American LegalNet, Inc. www.FormsWorkFlow.com Page 5 of 7 Revised (/2017) 11 c. Within the past 10 years, has the applicant ever been convicted of, or are there charges pending for, a misdemeanor theft offense as described in division (K)(3) of section 2913.01 of the Ohio Revised Code . Yes No 11 d. Has the applicant ever been excluded or directed to be excluded from participation in a Medicare or state health care program, or is any such action pending? Yes No 11 e. Has th e applicant ever been denied a license b