Fill and Sign the Work Related Violence Research Project Us Department of Form

New Jersey Office of the Attorney General Division of Consumer Affairs Board of Pharmacy 124 Halsey Street, 6th Floor, P.O. Box 45013 Newark, New Jersey 07101 (973) 504-6450 Application for an Out-of-State Pharmacy Registration Check Appropriate Box(es): New $175 Change of Name $175 Previous name: ____________________________________ Change of Ownership $175 Date of proposed acquisition ____________ Change of Location $175 Date of Proposed Relocation: ____________ The required fees must accompany the application. Make your check payable to the “New Jersey State Board of Pharmacy.” Do Not Send Cash. Applicant - Please print or type in the information requested below. Provide the PIC’s full name not his/her initials. Name of Pharmacy Area Code and Telephone Number Street Address Area Code and Fax Number City State Resident State Pharmacy Permit Number ZIP Code Toll-Free Telephone Number for Area Code and Telephone Number (if different) Patient/Pharmacist Communication Print Name of Pharmacist-in-Charge (PIC) PIC’s License Number PIC’s Weekly Hours of Employment Please affix below a copy of your prescription label used to ship controlled and noncontrolled substances into New Jersey:  Ownership Type - check one: Corporation* Partnership Individual Other On a separate sheet of paper, please provide the following information for each owner/officer, including professional designation (e.g. Pres. John Jones, M.D.) : • Name and title • Address (business and home) • Phone number (business and home) • Social Security number • Date of birth * If the pharmacy is a corporation, please complete: Date of incorporation___________ Name and address of the registered agent of the corporation: _____________________________________________ ______________________________________________________________________________________________ Is the corporation’s stock: Publicly traded; or Privately held? Pharmacy Hours of Operation Monday…….. ______ A.M. to ______ P.M. Friday…… ______ A.M. to _______ P.M. Tuesday……. ______ A.M. to ______ P.M. Saturday…______ A.M. to _______ P.M. Wednesday.. ______ A.M. to ______ P.M. Sunday…. ______ A.M. to _______ P.M. Thursday……______ A.M. to ______ P.M. Types of practice(s) in which the pharmacy is to engage: (Check all that apply) Mail Order Pharmacy Hospital Pharmacy Retail Pharmacy Nuclear Pharmacy Long-Term Care Pharmacy Sterile Compounding Non-Sterile Compounding Other, please indicate:__________________________________ Criminal/Disciplinary Action History – Pharmacist-in-Charge and/or Owner/Officer(s): Has the pharmacist-in-charge or any owner/officer of the pharmacy been or currently is: • The subject of any disciplinary action by any government agency; • The subject of any legal or adverse action by any law enforcement agency or any local, state or federal court; • Charged with the commission of any felony in any state or jurisdiction; • Convicted of a felony in any state or jurisdiction? Please indicate: Yes No If you answered “Yes,” to any of the above, please attach a letter of explanation as well as a certified copy of the final disposition for each incident. If the charges were dismissed, please provide a letter from the appropriate authority confirming dismissal of the charges. Criminal/Disciplinary Action History – Pharmacy: Has this pharmacy ever been the subject of any disciplinary or other adverse action by any other licensing agency, or by any other government agency, or by any local, state, or federal law enforcement agency, or by any local, state or federal court: Please indicate: Yes No If you answered “Yes,” to the above, please attach a letter of explanation as well as a certified copy of the final disposition for each incident. If the charges were dismissed, please provide a letter from the appropriate authority confirming dismissal of the charges.  Affidavit: Affidavit A below, must be completed by the owner, partner or by the principal officer as designated above. If the person executing Affidavit “A” is not also the pharmacist-in-charge of the pharmacy, then the pharmacist-in-charge must complete Affidavit “B.” Please note that each affidavit must be sworn to before a Notary Public or other authorized officer. I do solemnly swear and affirm that the foregoing statements on this form or those on any attachment(s) to this form are to the best of my knowledge true and correct. Affidavit “A” Affidavit “B” ______________________________________________ Print Name of Owner, Partner or Officer ______________________________________________ Print Name of Pharmacist-in-Charge ______________________________________________ Signature of above ______________________________________________ Signature of above Subscribed and sworn to before me this ______________ Subscribed and sworn to before me this ______________ day of ________________ in the year _______________ day of ________________ in the year _______________ Print Notary’s name: Print Notary’s name: ______________________________________________ ______________________________________________ Notary’s signature: Notary’s signature: ______________________________________________ ______________________________________________ My commission expires ___________________________ My commission expires ___________________________ Affix Seal Here: Affix Seal Here: Required documentation which must be enclosed with this application: • A dated copy of the most recent inspection report resulting from an inspection of this pharmacy conducted by the regulatory or licensing agency in the state or jurisdiction in which this pharmacy is located. • A certified letter of good standing from the licensing authority in the state or jurisdiction in which this pharmacy is licensed, permitted or registered. Note: Unless this required documentation is supplied, the application cannot be processed.