Date Stamp Here Revenue: 0262010000 Fees (Check all that apply) F Pharmacy Location .............................Fee F ControlledSubstanceAct ....................Fee F AncillaryUtilization ..............................Fee (Completeadditionalapplication) F Differential Hours ................................Fee (Completeadditionalapplication) Check the online fee page for current fees Allapplicationfeesarenonrefundable. Pharmacy License Application Thisisfor: New F F Change of Ownership F Change of Location ­ Current License # __________ F Name Change Only ­ Current Facility Name ______________________________________ Check One F Association F Corporation F FederalGovernmentAgency F LimitedLiabilityCompany F LimitedLiabilityPartnership F LimitedPartnership F Municipality (City) F Municipality (County) F Non-ProfitCorporation F Partnership F SoleProprietor F StateGovernmentAgency F TribalGovernmentAgency F Trust 1. Demographic Information UBI# FederalTaxID(FEIN)# Legal Owner/Operator Name MailingAddress City State ZipCode County Phone(enter10digit#) EmailAddress Fax(enter10digit#) WebAddress: Facility/AgencyName(BusinessnameasadvertisedonsignsorWebsite) PhysicalAddress City State ZipCode County FacilityPhone(enter10digit#) EmailAddress: Fax(enter10digit#) MailingAddress(Ifdifferentthanphysicaladdress) City State ZipCode County American LegalNet, Inc. www.FormsWorkFlow.com DOH 690-152 December 2013 Page 1 of 3 2. Facility Information Type of Pharmacy F Community/Retail FMail-Order Monday­Friday F Hospital F Nuclear F Jail F Parenteral F Long-term Care (LTC) F Internet FCompounding Sunday Holidays Pharmacy Hours--Indicatethehoursthepharmacywillbeopen Saturday DrugEnforcementAdministration(DEA)RegistrationNumber DEANumber:_____________________________________ Background Questions YesNo F 1. Haveanyapplicants,partners,ormanagershadasuspension,revocation,orrestriction of a professional license? .........................................................................................................................F Ifyes,listandexplainonaseparatesheetofpaper. 2. Haveanyapplicants,partners,ormanagersbeenfoundguiltyofadrugorcontrolled substance violation? .................................................................................................................................F Ifyes,listandexplainonaseparatesheetofpaper. F Pharmacist in Charge Pharmacist in Charge License Number Date of Appointment 3. Contact Information Name ContactPerson ContactPerson Title Phone(enter10digit#) Phone(enter10digit#) EmailAddress EmailAddress Name Title 4. Additional Information DateofIncorporation CorporateNumber StateofCorporation Name Legal Owner Information­attach additional completed pages if you need more space. Listnames,addresses,phonenumbers,andtitlesofcorporateofficers,partners,membersandmanagers. Address Phone(enter10digit#) Title American LegalNet, Inc. www.FormsWorkFlow.com DOH 690-152 December 2013 Page 2 of 3 Change of Ownership Information Previous Name of Legal Owner Previous Name of Facility Previous Pharmacy License # Effective Date of Ownership Change List all Pharmacist­attach additional completed pages if you need more space. Name License # Signature IcertifyIhavereceived,read,understood,andagreetocomplywithstatelawandruleregulatingthislicensing category.Ialsocertifytheinformationhereinsubmittedistruetothebestofmyknowledgeandbelief. SignatureofOwner/AuthorizedRepresentativeofPharmacy Date Print Name Print Title American LegalNet, Inc. www.FormsWorkFlow.com DOH 690-152 December 2013 Page 3 of 3