Wisconsin Department of Safety and Professional Services Mail To: P.O. Box 8935 FAX #: Phone #: 1400 E. Washington Avenue Madison, WI 53703 E-Mail: web@dsps.wi.gov Website: http://dsps.wi.gov Madison, WI 53708-8935 (608) 261-7083 (608) 266-2112 PHARMACY EXAMINING BOARD OUT-OF-STATE PHARMACY LICENSE APPLICATION PLEASE TYPE OR PRINT IN INK Your name and address are available to the public. Check box to withhold street address/PO Box number from lists of 10 or more credential holders (Wis. Stat. § 440.14) CURRENT WI LICENSE NO.: NEW PHARMACY APPLICATION CHANGE OF OWNERSHIP ___________________________ CHANGE OF LOCATION PLEASE TYPE OR PRINT IN INK. APPLICANT: DBA: individual, partnership, association or corporation Name or title under which business is operated. (This must be the name on the pharmacy label.) number, street, city, zip code MAILING ADDRESS: ( ) FAX NO. PHARMACY ADDRESS: TELEPHONE NO. ( ) COUNTY number, street, city, zip code NAME OF OWNER OR NAMES AND TITLES OF ALL PARTNERS OR CORPORATE OFFICERS AND PERCENTAGE OF OWNERSHIP. (Attach additional sheets if necessary.) NAME % NAME % _____________________________________________ _______ ______________________________________________ ________ _____________________________________________ _______ ______________________________________________ ________ Pharmacy license number in state where the pharmacy is physically located. State: License Number: ___________________________ ___________________________ Enclose copy of current license, permit, or registration certificate issued by the regulatory authority of the home state or territory OR letter from such authority certifying the pharmacy’s compliance with the pharmacy and controlled substances laws of the home state. Enclosed (check one): license compliance letter Managing Pharmacist State License # DATE OF PURCHASE OF PHARMACY - date of sale to be signed (For Change of Ownership only) (This is required for a Change in Ownership or Change in Location.) PROPOSED OPENING DATE PROPOSED CLOSE DATE OF CURRENT LICENSE # (This is required for a Change in Ownership or Change in Location.) PHARMACY HOURS - Daily (open - close) An out-of-state pharmacy shall provide a telephone number that allows a person in Wisconsin to contact the pharmacy during the pharmacy’s regular hours of business and that is available for use by a person in Wisconsion for not less than 40 hours per week. The label of all prescription drug containers shiopped, mailed or otherwise delivered to a person in Wisconsoin must bear the telephone number of the out-of-state pharmacy. Telephone No.: ( ) For Receipting Use Only - APPLICATION FEE: Please make check payable to Department of Safety and Professional Services and attach to application. $75.00 #2737 (Rev. 9/11) Ch. 450, Stats. Initial Credential Fee -OVERAmerican LegalNet, Inc. www.FormsWorkFlow.com Committed to Equal Opportunity in Employment and Licensing American LegalNet, Inc. www.FormsWorkFlow.com Wisconsin Department of Safety and Professional Services Statement of Owner or Managing Pharmacist Statement from the owner of the pharmacy or; If the pharmacy is not a sole proprietorship, from the managing pharmacist of the pharmacy; This is to certify that I have read and approved the foregoing and the statements are true and correct to the best of my knowledge and belief; and that I know the laws relating to the practice of pharmacy in Wisconsin. ___________________________________________________ (Owner, if a sole proprietorship) ____________________________________ Date ___________________________________________________ PRINTED NAME This is to certify that I have read and approved the foregoing and the statements are true and correct to the best of my knowledge and belief; and that I know the laws relating to the practice of pharmacy in Wisconsin. ___________________________________________________ (Managing Pharmacist, if not a sole proprietorship) ____________________________________ Date ___________________________________________________ PRINTED NAME State License # ______________________________________ American LegalNet, Inc. www.FormsWorkFlow.com