Revenue Section P.O. Box 1099 Olympia WA 98507-1099 360.236.4700 Nonresident Pharmacy License Application Packet 1. 690-159.....Application Packet Index Page................................................................... 1 Page 2. 690-160.....Application Checklist & Instructions.......................................................... 2 Pages 3. 690-152.....License Application................................................................................... 3 Pages Important Information: Mail application and check or money order to: Department of Health Revenue Section P.O. Box 1099 Olympia, WA 98504-1099 DOH 690-159 (REV 4/2008) American LegalNet, Inc. www.FormsWorkFlow.com Revenue Section P.O. Box 1099 Olympia WA 98507-1099 360.236.4700 Nonresident Pharmacy License Application Checklist & Instructions Fees: Check one; with controlled substance or without controlled substance. Indicate type of application – new, change of ownership, change of location, or name change. New – First time requesting a pharmacy license. Consult fee schedule for fee amount required. Change of Ownership – When name of legal owner/operator changes resulting from the sale of licensed agency. Change of Location – Changing the location address of pharmacy. Be sure to include your current license number. Name Change Only – Changing the name of your pharmacy. Be sure to list your current facility name.  Check One: Please check your legal owner/operator business structure type according to your Washington State Master Business License.  Section #1: Demographic Information: Uniform Business Identifier Number (UBI #): Enter your Washington State UBI #. All Washington State businesses must have UBI #’s. City, county, and state government departments also have UBI#’s. Federal ID Number (FEIN #): Enter your Federal ID Number, if the business has been issued one. Legal Owner/Operator Name: Enter the owner’s name as it appears on the UBI/ Master Business License. Mailing Address: Enter the owner’s complete mailing address. Phone and Fax Numbers: Enter the owner’s phone and fax number. Email and Web Address: Enter the owner’s email and agency Web addresses, if applicable. Facility/Agency Name: Enter the agency’s name as advertised on signs, brochures or Web site. Physical Address: Enter the agency’s physical street location including city, state, zip and county. Phone and Fax Numbers: Enter the agency’s phone and fax number. Mailing Address: Enter the agency’s mailing address, if different than physical address. DOH 690-160 (REV 4/2008) 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com  Section #2: Facility Specific Information: Type of Pharmacy: Please check which type of pharmacy you are applying for; community retail, hospital, jail, long-term care, mail-order, nuclear, parenteral, or internet (include web address). Hours Pharmacy will be open: Enter hours pharmacy will be open for MondayFriday, Saturday, Sunday, and any holiday hours you’ll be open. Pharmacy Toll-free Number: You are required to provide a toll-free number to be licensed as a pharmacy. Drug Enforcement Administration (DEA) number: Enter DEA number here. Date of last resident state inspection: Indicate date of last resident state inspection and be sure to attach a copy of last inspection. Background Questions: Check yes or no and if you check yes, list and explain on a separate sheet of paper.  Section #3: Key Individuals: Enter name, title, phone number, fax number, and email address.  Section #4: Supervision: Enter name of pharmacist in charge, license number, and date of appointment.  Section #5: Additional Information: Corporation information: Enter date of incorporation, corporate number, and state of corporation. Legal Owner: List the names, titles, addresses, and phone numbers of the corporate officers, partners, member, managers, etc. Attach additional sheet, if necessary. Change of Ownership Information: If applicable, list the previous legal owner name, previous name of facility, previous license #, effective date of ownership change and physical address. List of Pharmacists: List all pharmacists working in your pharmacy. Attach additional sheets if needed. Agent of Record: List name of agent of record, address, and telephone number. Written Explanation: Provide a written explanation of the method used to maintain readily retrievable records of sales of controlled substances, legend drugs, and medical devices to individuals in the state of Washington. Other States of Licensure: List any other states you have been licensed.  Signature: Signature of legal owner or authorized representative. Date signed. Print name of legal owner or authorized representative. Print title of legal owner or authorized representative. DOH 690-160 (REV 4/2008) 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Revenue Section P.O. Box 1099 Olympia WA 98507-1099 360.236.4700 Date Stamp Here Revenue: 0262010000 Fees (check all that apply)  Without controlled substance................. $365 .  With controlled substance...................... $445 . All application fees are nonrefundable Nonresident Pharmacy License Application This is for:  New  Change of Ownership  Change of Location – Current License #_ _____________ _  Name Change Only ($15.00 duplicate fee.) – Current Facility Name___________________________ Check One  Association  Corporation  Federal Government Agency  Limited Liability Company  Limited Liability Partnership  Limited Partnership  Municipality (City)  Municipality (County)  Non-Profit Corporation  Partnership  Sole Proprietor  State Government Agency  Tribal Government Agency  Trust 1. Demographic Information UBI # Federal Tax ID (FEIN) # Legal Owner/Operator Name Mailing Address City State Zip County Phone# Fax# ( ) ( ) Email Address Web Address: Facility/Agency Name (Business name as advertised on signs or Web site) Physical Address City State Zip Facility Phone# Fax# ( ) ( Mailing Address (If different than physical address) City State Zip County ) County DOH 690-152 (REV 4/2008) Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 2. Facility Specific Information Type of Pharmacy (Check all that apply)  Community/Retail  Mail-Order  Hospital  Nuclear  Long-term Care (LTC)  Internet  Jail  Parenteral Pharmacy Hours (Indicate the hours the pharmacy will be open) Monday–Friday Saturday Sunday Holidays Toll-free Phone Number (You must provide a toll-free number for your pharmacy to become licensed) Pharmacy Toll-free Number__________________________ Date of last inspection (attach copy):_ ____________________________________ Drug Enforcement Administration (DEA) #_ ________________________________ Background Questions Yes No 1. Have any applicants, partners, or managers had a suspension, revocation, or restriction of a professional license?..........................................................................................................................  If yes, list and explain on a separate sheet of paper. 2. Have any applicants, partners, or managers been found guilty of a drug or controlled substance violation?..................................................................................................................................  If yes, list and explain on a separate sheet of paper. 3. Key Individuals Contact Person Name Email Address Title Telephone Number ( ) Email Address Title Telephone Number ( ) License Number Date of Appointment Contact Person Name 4. Supervision Pharmacist in Charge 5. Additional Information Date of Incorporation Corporate Number State of Corporation Legal Owner Information–attach additional sheets as needed List names, addresses, phone numbers, and titles of corporate officers, partners, members, managers, etc. Name Address Phone # Title DOH 690-152 (REV 4/2008) Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Change of Ownership Information Previous Name of Legal Owner Previous Name of Facility Previous Pharmacy License # Effective Date of Ownership Change Physical Address List all Pharmacist–attach additional sheets if needed Name License # Agent of Record in Washington for Service of process (cannot use the Secretary of State’s Office) Name of Agent of Record Address Telephone Number ( ) Written Explanation Provide a written explanation of the method used to maintain readily retrievable records of sales of controlled substances, legend drugs, and medical devices to individuals in the state of Washington. ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Other States of Licensure (list below) Signature I certify that I have received, read, understood, and agree to comply with state law and rule regulating this licensing category. I also certify that the information herein submitted is true to the best of my knowledge and belief. ___________________________________________________________ Signature of Owner/Authorized Representative of Pharmacy _ ____________________________________ _ Date ___________________________________________________________ Print Name _ ____________________________________ _ Print Title DOH 690-152 (REV 4/2008) Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com