Vermont Secretary of State Office of Professional Regulation VERMONT BOARD OF PHARMACY National Life Building, North, FL 2 Montpelier, VT 05620-3402 Ph: (802) 828-2373 or 828-1505 Fax: (802) 828-2465 E-Mail: “kkemp@sec.state.vt.us” Web Site: www.vtprofessionals.org INSTRUCTION SHEET FOR NON-RESIDENT (OUT-OF-STATE) DRUG OUTLET (PHARMACY) You may contact Kristy Kemp, Administrative Assistant, at (802) 828-2373 or via E-mail: kkemp@sec.state.vt.us if you have questions or if you need additional information. Once your application is complete, it will be sent to the Board for review. The Board usually meets on the fourth Wednesday of each month. See the Board’s Web site for specific meeting dates, agendas, minutes, etc. This application applies to out-of-state (Non-Resident) drug outlets or pharmacies. See Part 16 of the Board’s Rules. http://vtprofessionals.org/opr1/pharmacists/rules.asp “Non-resident pharmacy” means a drug outlet located outside of this state which dispenses prescription drugs or devices to Vermont residents or residents of other states and which mails, ships, or delivers such prescription drugs or devices into this state or which provides any type of pharmacy services. All signatures required on the application must be those of an Owner, a Partner, or Corporate Officer. Non-Resident Pharmacies / Drug Outlets must submit the following: 1. Completed application 2. Application fee of $300.00. Please make your check payable to Vermont Secretary of State. Application fees are non-refundable. 3. Verification of licensure standing directly from the licensing authority in the state where the pharmacy is located that will be shipping drugs to Vermont. No form is provided. Contact your state’s Board of Pharmacy or applicable licensing authority and request that a verification of good standing be sent to Vermont. Note: Online verification is acceptable provided the state in which the facility is located reports whether disciplinary action(s) has been taken against the applicant. 4. List(s) of the names of all owners. Indicate whether sole proprietor, partnership, corporation, limited liability company, etc. Note: Changes in ownership require submittal of a new application. Provide a flow chart showing ownership. If an actual flow chart is not available, a description of the ownership or hierarchy of the organization is acceptable. (See Board Rule 16.2 (c)) (1) If a person: the name, business address, and date of birth; (2) If a partnership: the name, business address, and date of birth of each partner, and the name of the partnership; (3) If a sole proprietorship: the full name, business address, social security number, and date of birth of the sole proprietor and the name of the business entity; and (4) If a corporation: the federal identification number of the corporation, the name, business address, date of birth, and title of each corporate officer and director, the corporate names, the name of the state of incorporation, and the name of the parent company, if any; the name, business address of each shareholder owning five percent or more of the voting stock of the corporation, including over-thecounter stock, unless the stock is traded on a major stock exchange and not over-the-counter; American LegalNet, Inc. www.FormsWorkFlow.com 5. Affirmation Forms completed by the sole proprietor, all members, all partners, or corporate officers and directors, and the pharmacist-manager, that they have not been convicted of, and are not under indictment for, any felony or misdemeanor arising from the violation of any drug or pharmacy related law. Questions must be answered and your signature must be notarized. (Rule 16.2) 6. Required Statement(s). The Pharmacist Manager may sign the form provided with this application regarding the required statements or may make the statements on pharmacy letterhead. A copy of the prescription label with toll free number may be applied to this statement or attached separately. (See Board Rule 16.2 (e) (f) and (g)). 7. A copy of the most recent inspection report from the state in which the pharmacy is located; and Effective July 1, 2010: For internet non-resident pharmacies, a copy of an inspection report not more than three years old by either: (1) the state in which the pharmacy is located; or (2) Verified Internet Pharmacy Practice Sites (VIPPS) certification. Where the Pharmacy Board in the other state has not inspected the pharmacy in the past three years through no fault of the pharmacy, the pharmacy may advise this Board of the inspection delay and this Board may grant the pharmacy an extension of up to one year to allow the pharmacy to comply with this rule. 8. Disciplinary Actions or Denials: Answers to these questions pertain to the applicant, its parent, subsidiaries, or another person or organization with a controlling interest in the drug outlet. If the answer is “yes” on the application form, provide certified copies of the charges, if filed, and of the Final Disposition Order. In addition, a signed and sworn statement from the CEO, COO, president or equivalent management level corporate officer showing how the company has responded to the prior violation such that the Vermont Board of Pharmacy can be assured that a repeat or similar violation will not occur in Vermont. Please also ask the state in which the action was taken to provide to the Board verification of current licensure standing. An Investigative Team will review this information to determine whether further investigation or action is needed before a final decision is made regarding your application. If your Internet Pharmacy is certified by the National Association of Boards of Pharmacy’s Verified Internet Pharmacy Practice Sites (VIPPS) program, please provide a copy of your certification. For more information contact the NABP via www.nabp.net. NOTE: All licensees renew on a fixed 24 month schedule: July 31 (odd numbered years). Applicants issued an initial license more than 90 days prior to the renewal date will be required to renew and pay the renewal fee. Initial licenses issued within 90 days of the renewal date will not be required to renew or pay the renewal fee. The Statutes and Rules are available via the Board’s Web site at: http://vtprofessionals.org/opr1/pharmacists/rules.asp www.vtprofessionals.org American LegalNet, Inc. www.FormsWorkFlow.com Vermont Secretary of State Office of Professional Regulation National Life Building, North FL 2 Montpelier VT 05620-3402 (802) 828-1505 Kristy Kemp Administrative Assistant (802) 828-2373 kkemp@sec.state.vt.us www.vtprofessionals.org Board of Pharmacy Non-Resident Drug Outlet Change in Ownership Application Name of Pharmacy City, State, Zip Mailing Address, Street Phone Fax Email Current Vermont license number to be inactivated: Federal Identification Number Social Security No. (sole proprietor) _____/___________________ _____/_____/____________ LEGAL ORGANIZATION: Corporation ____Foreign Corporation Individual Partnership Limited Liability Company _____If Other, Indicate: Name of Owner (entity or Individual) List the name, date of birth and address of the sole proprietor, partners, members, etc. Name of individual owner(s) Date of Birth Mailing Address If corporate owner, provide names and addresses of officers and shareholders owning 5% or more. (Attach separate sheet if necessary). If no individual shareholder owns 5% or more, please state that fact below. Shareholder’s Name Date of Birth Mailing Address American LegalNet, Inc. www.FormsWorkFlow.com Name(s) and license number(s) of all pharmacists employed by the pharmacy, including employer if employer is a pharmacist. Pharmacist Manager’s Name License Number Hours Pharmacy open per week Hours worked per week Name of other Pharmacists employed here License Number Hours Pharmacy open per week Hours worked per week Toll Free Number: Indicate hours that the pharmacy is open for business. Sunday Monday Tuesday Wednesday Thursday Friday Saturday Drug Enforcement Administration: Is the applicant registered under the Controlled Substances Act? If Yes, provide a copy of your DEA Number Issued. Yes No American LegalNet, Inc. www.FormsWorkFlow.com Vermont Mandatory “Good Standing” Declarations CHILD SUPPORT: Child Support Orders, 15 V.S.A. § 795 As of the date of this application: this business, and/or the person signing this form, (check one) ___Is not subject to a child support order; OR ___Is subject to a child support order and am in good standing* or in full compliance with a plan to pay ___Is not in good standing* or in full compliance with a plan to pay.* TAXES: Tax Compliance, 32 V.S.A. § 3113(b) As of the date of this application: this business, and/or the person signing this form, (check one) ___ Has never lived or worked in Vermont and do not owe Vermont taxes; OR ___ Has no taxes due and payable and all required returns have been filed; OR ___ Has the liability for any taxes due and payable on appeal; OR ___ Is not in compliance with a payment plan approved by the Vermont Department of Taxes; OR ___ Is not in good standing* with the Vermont Department of Taxes or in full compliance with a plan to pay. UNEMPLOYMENT COMPENSATION: Unemployment Compensation, 21 V.S.A. §1378(b) As of the date of this application: this business, and/or the person signing this form, states that: (check one) ___This does not apply because this business or I have never been an employer in Vermont; OR ___ No contributions or payments in lieu of contributions are due and payable; or the liability for any contributions or payments in lieu of contributions due and payable is on appeal; or the employing unit is in compliance with a payment plan approved by the commissioner; OR ___ this business or I am not in good standing* or in full compliance with a plan to pay. DISTRICT COURT FINES / JUDICIAL BUREAU: Unpaid Judgments, 4 V.S.A. § 1110(c) As of the date of this application: this business, and/or the person signing this form: (check one) _____Does not have any unpaid judgements _____Is in good standing* with respect to any unpaid judgment issued by the judicial bureau or district court for fines or penalties for a violation or criminal offense.” _____Is not in good standing.* * “Good standing” is defined in the statutes cited above. For more information, refer to the relevant statute specific to the particular question or consult the “information for applicants” on the OPR web page. (www.vtprofessionals.org) American LegalNet, Inc. www.FormsWorkFlow.com Please note, answers to the questions apply to the applicant, its owner or parent, subsidiaries or any another person or entity with a controlling interest in this organization. Vermont Mandatory Credential and Fitness Questions Please circle Yes or No for each of these questions. If “Yes,” follow the provided instructions. Has Vermont or any other state, federal authority, or other jurisdiction (US or elsewhere) denied an application for a license, certificate, or registration by this applicant to conduct business or perform professional services? If “Yes,” attach a copy of the order or official notification of the action(s). Yes No Has Vermont or any other state, federal authority or other jurisdiction (US or elsewhere) restricted, suspended, revoked, or taken any other disciplinary action against a license, certificate, or registration held by this applicant to conduct business or perform professional services? If “Yes,” provide a copy of the order or official notification of the action. Yes No Has the entity for which this application is submitted ever surrendered a license, certificate or registration to a licensing authority? If “Yes,” provide a detailed written explanation. Yes No Is the entity for which this application is submitted currently under investigation by a licensing authority? If “Yes,” provide a detailed written explanation and a copy of any available information from the licensing authority. Yes No Yes No Yes No Has the entity for which this application is submitted been convicted of a crime? If “yes,” provide a detailed written explanation and attach the official court documents. Does the entity for which this application is submitted have any criminal charges pending against it in any jurisdiction (US or elsewhere)? If ”yes,” provide a detailed written explanation and attach a copy of the charging documents. Note: Vermont law requires that you report to the Office of Professional Regulation a felony conviction or any conviction of a crime related to the practice of your profession, within 30 days. 3 V.S.A. § 129a (a)(11). Statement of Applicant I certify, under the pains and penalties of perjury, that all information I have provided in this application is true and accurate. I understand that furnishing false information may constitute unprofessional conduct and result in the denial of this application for licensure/certification/registration. The maximum penalty for perjury is fifteen years in prison and/or a $10,000 fine. (13 V.S.A. §2901) I further certify that I have read and understand the laws and rules of the profession (www.vtprofessionals.org). Signature of Applicant Date Print Name and Title of proprietor, partner, member or corporate officer: Revised 02/2011 American LegalNet, Inc. www.FormsWorkFlow.com Vermont Secretary of State, Office of Professional Regulation VERMONT BOARD OF PHARMACY National Life Building, North, FL 2, Montpelier, VT 05620-3402 www.vtprofessionals.org – (802) 828-2373 AFFIRMATION Name of Pharmacy (Applicant) Your Name Your Address City, State, Zip Date of Birth Email Address Check Applicable position or title: ____ Sole Proprietor ____ Partner ____ Corporate Officer ____ Director ____ Pharmacist-Manager ____ Other The Board’s Rules require an Affirmation by the sole proprietor, all partners, members, or corporate officers and directors, and the pharmacist-manager, that they have not been convicted of, and are not under indictment for, any felony or misdemeanor arising from the violation of any drug or pharmacy related law. Answer the questions below. If “Yes,” provide documentation. Have you been convicted of, or under indictment for, any felony or misdemeanor arising from the violation of any drug or pharmacy related law? If “Yes,” attach court documents. Has Vermont, any other state, territory, or other jurisdiction restricted, suspended, revoked, or taken any other disciplinary action against a license, certificate, or registration that you hold or held in any profession or occupation? If “Yes,” provide a certified copy of the action. Has Vermont, any other state, territory, or other jurisdiction denied your application for a license, certificate, or registration in any profession or occupation? If “Yes,” provide a certified copy of the order or official notification of the Board action. Yes No Yes No Yes No CERTIFICATION OF APPLICANT I certify, under the pains and penalties of perjury, that all information I have provided in this application is true and accurate. I understand that furnishing false information may constitute unprofessional conduct and result in the denial of my application for licensure/certification/registration. (The maximum penalty for perjury is Fifteen years in prison and/or a $10,000 fine.) (13 V.S.A. §2901) Signature: ___________________________________________ STATE OF _________________________________ COUNTY OF Date: ____________________ _ }ss. Subscribed and sworn to before me this ________ day of ____________________, 20_________ (year) ____________________________________________ Commission Expires: ___________________ Notary Public American LegalNet, Inc. www.FormsWorkFlow.com Vermont Secretary of State Office of Professional Regulation VERMONT BOARD OF PHARMACY National Life Building, North, FL 2 Montpelier, VT 05620-3402 Ph: (802) 828-2373 Fax: (802) 828-2465 E-Mail: “kkemp@sec.state.vt.us” STATEMENT(S) OF PHARMACIST MANAGER Board Rule 16.2 (e) (f) and (g) Name of Pharmacy Address of Pharmacy Print Your Name as Pharmacist Manager Attesting to Statements below 1. I certify that the Applicant has the ability to provide to the Board a record of a prescription drug order dispensed by the applicant to a resident of this state not later than 72 hours after a request for the record by the Board. 2. I certify that I am the pharmacist-manager and that I have read and understand the Vermont laws and rules relating to a non-resident pharmacy. http://vtprofessionals.org/opr1/pharmacists/rules.asp 3. I certify that during its regular hours of operation, but not fewer than six days per week, for a minimum of 40 hours per week, a toll-free telephone service is provided to facilitate communication between patients in this state and a pharmacist at the pharmacy who has access to the patients’ records. The toll-free number must be disclosed on the label affixed to each container of drugs dispensed to residents of this state; and evidence that during its regular hours of operation, but not fewer than six days per week, for a minimum of 40 hours per week, a toll-free telephone service is provided to facilitate communication between patients in this state and a pharmacist at the pharmacy who has access to the patients’ records. The toll-free number must be disclosed on the label affixed to each container of drugs dispensed to residents of this state. Statement of Applicant I certify, under the pains and penalties of perjury, that all information I have provided in this application is true and accurate. I understand that furnishing false information may constitute unprofessional conduct and result in the denial of my application or further disciplinary action. The maximum penalty for perjury is fifteen years in prison and/or a $10,000 fine. (13 V.S.A. §2901) Signature of Pharmacist Manager Date Affix Prescription Label below or provide separately. American LegalNet, Inc. www.FormsWorkFlow.com