Nonresident Pharmacy License Application Packet Contents: 1. 690-253....Contents List/Mailing Information..................................................... 1 Page 2. 690-254....Application Instructions Checklist................................................... 2 Pages 3. 690-255....Nonresident Pharmacy License Application................................... 3 Pages 4. RCW/WAC and Online Web Site Links............................................................. 1 Page In order to process your request: Mail your application with initial documentation and your check or money order payable to: Send other documents not sent with initial application to: Department of Health PO Box 1099 Olympia, WA 98507-1099 Board of Pharmacy Credentialing PO Box 47877 Olympia, WA 98504-7877 Contact us: 360.236.4700 DOH 690-253 September 2012 American LegalNet, Inc. www.FormsWorkFlow.com (This page intentionally left blank.) American LegalNet, Inc. www.FormsWorkFlow.com Application Instructions Checklist When your application for nonresident pharmacy license is received by the Department of Health, you will be notified in writing of any outstanding documentation needed to complete the application process. Indicate type of application—New, change of ownership, change of location, or name change. • New—First time requesting a nonresident pharmacy license. • Change of Ownership—When name of legal owner/operator changes resulting from the sale of licensed nonresident pharmacy. • Change of Location—Include your current license number. • Name Change Only—List your current facility name. FF Check One: Please check your legal owner/operator business structure type according to your Washington State Master Business License. FF Application Fees: Check one; with controlled substance or without controlled substance. Fees are non-refundable. You can check the online fee page for current fees. FF 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 you have them. Facility/Agency Name: Enter the agency’s name as advertised on signs, brochures or Web sites. Physical Address: Enter the agency’s physical street location including city, state, zip code, 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. Email Address: Enter the agency’s email address, if available. DOH 690-254 September 2012 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com FF 2. Facility 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 that will 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) Registration Number: Enter the Federal DEA registration number if dispensing controlled substances. Enter “pending” if the pharmacy has not been issued its DEA registration number. 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. Pharmacist in Charge: Enter pharmacist name, license number, and date of appointment. FF 3. Contact Information: Enter name, title, phone number, fax number, and email address. FF 4. 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, members, and managers. Attach additional completed pages if you need more space. Change of Ownership Information: List the previous legal owner name, previous name of facility, previous license number, and effective date of ownership change. List of Pharmacist: List all pharmacists working in your pharmacy. Attach additional completed pages if you need more space. Agent of Record for Process Services: List the entity or individual that will serve as an agent of record that will accept legal services on behalf of the pharmacy, the agent’s address, and telephone number. The agent of record must be located in Washington State. The secretary of State’s office cannot serve as an agency of record. 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 Washington State. FF 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 690-254 September 2012 page 2 of 2 Inc. American LegalNet, www.FormsWorkFlow.com Date Stamp Here Revenue: 0262010000 Fees (check all that apply)  Without controlled substance..................... fee  With controlled substance.......................... fee All application fees are nonrefundable You can check the online fee page for current fees. Nonresident Pharmacy License Application This is for:  New  Change of Ownership  Change of Location—Current License #_______________  Name Change Only—Current Facility Name______________________________________________ Check One  Association  Corporation c Federal Government Agency  Limited Liability Company  Limited Liability Partnership c Limited Partnership c Municipality (City) c Municipality (County)  Non-Profit Corporation  Partnership c Sole Proprietor c State Government Agency c Tribal Government Agency  Trust 1. Demographic Information UBI # Federal Tax ID (FEIN) # Legal Owner/Operator Name Mailing Address City State Zip Code County Phone (enter 10 digit #) Fax (enter 10 digit #) Email Address Web Address: Facility/Agency Name (Business name as advertised on signs or Web site) Physical Address City State Zip Code County Facility Phone (enter 10 digit #) Fax (enter 10 digit #) Email Address Mailing Address (If different than physical address) City State Zip Code County For Office Use Only License #________________________________________________ Issue Date___________________________________________ Page 1 of 3 DOH 690-255 September 2012 American LegalNet, Inc. www.FormsWorkFlow.com 2. Facility Information Type of Pharmacy (Check all that apply) c Community/Retail c Hospital c Mail-Order c Nuclear Pharmacy Hours (Indicate the hours the pharmacy will be open) Monday–Friday c Long-term Care (LTC) c Internet c Jail c Parenteral 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) Registration #_______________________ 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. Pharmacist Consultant License Number Date of Appointment Name 3. Contact Information Contact Person Phone (enter 10 digit #) Email Address Phone (enter 10 digit #) Email Address Name Title Contact Person Name Title 4. Additional Information Date of Incorporation Corporate Number State of Corporation Legal Owner Information-attach additional completed pages if you need more space. List names, addresses, phone numbers, and titles of corporate officers, partners, members, and managers. Name Address Phone (enter 10 digit #) Title DOH 690-255 September 2012 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 List all Pharmacist–attach additional completed pages if you need more space. Name License # Agent of Record in Washington State for Service of process (cannot use the Secretary of State’s Office) Name of Agent of Record Address Phone (enter 10 digit #) 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 Washington State. Other States of License (list below) Signature I certify I have received, read, understood, and agree to comply with state law and rule regulating this licensing category. I also certify 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 690-255 September 2012 Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com (This page intentionally left blank.) American LegalNet, Inc. www.FormsWorkFlow.com RCW/WAC and Online Web Site Links RCW/WAC Links Uniform Disciplinary Act.............................................................................. RCW 18.130 Administrative Procedure Act..........................................................................RCW 34.05 Administrative procedures and requirements............................................... WAC 246-12 Pharmacy RCW...............................................................................................RCW 18.64 Pharmacy WAC.......................................................................................... WAC 246-869 On-Line AIDS Training Resources....................................................................... Reference Page Pharmacy Board............................................................................................... Web Page RCW/WAC and Online Web Site Links September 2012 American LegalNet, Inc. www.FormsWorkFlow.com