Fillable Pharmacy Permit Application (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Pharmacy Permit Application (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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The Pharmacy Permit Application (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General) form is 6 pages long and contains:

  • 6 signatures
  • 39 check-boxes
  • 80 other fields

Country of origin: US
File type: PDF

U.S.A. forms for State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General

BROWSE STATE OF NEW JERSEY, DEPT. OF LAW & PUB. SAFETY, OFFICE OF THE ATTORNEY GENERAL (NJ) FORMS

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
Board of Pharmacy
124 Halsey Street, 6th Floor, PO Box 45013,
Newark, NJ 07101
(973) 504-6450
Pharmacy Permit Application
Thisapplicationmustbelledincompletely,sworntoandmailedtotheBoardofPharmacywithafeeof$275.00.Makethe
checkormoneyorder(donotsendcash)payabletotheBoardofPharmacy.
Pleaseprintclearly.
PursuanttoN.J.S.A.45:14-40,Iorwe,____________________________________________,herebymakeapplicationfor
a permit to conduct the pharmacy referred to below until June 30th next, and certify to the correctness of the following
information:
(Pleasechecktheappropriateboxbelow.Listthepresentowneroraddresswhereapplicable.)
Transferofownershipfrom___________________________________________________________________________
Changeoflocationfrom_____________________________________________________________________________
Remodeling
Newpharmacy
1. (a)Nameunderwhichpharmacyistobeoperated:________________________________________________________
(b)Istheabovenameregisteredintheofceofthecountyclerk? Yes No
(c)Telephonenumber:_________________________________

(includeareacode)
(d) _____________________________________________________________________________________________

Streetaddressofpharmacy Nearestcrossstreet
_____________________________________________________________________________________________

CityStateZIPcodeCounty
2.Typeofpermit: Retail Institutional
Typeofpractice(s)inwhichthepharmacyistoengage:(Checkallthatapply.)
Standardretailpharmacy Retailpharmacydepartment  Long-TermCarepharmacy
Mailorderpharmacy Nuclearpharmacy Sterileadmixtureretail
Hospitalpharmacy Hospitalsatellitepharmacy  Specialtypharmacy
Other,pleaseindicate:______________________________________
3. Ifapplicationisnotbeingmadeforacorporation,listbelowthenamesandaddressesofindividuals,partners,trustees,
receivers,executorsorotherpersonsinwhomownershipwillbevested.
_________________________________________________________________________________________________

Fullnameofowner HomeaddressPercentageofownershipR.Ph.LicenseNumber
_________________________________________________________________________________________________

Fullnameofowner HomeaddressPercentageofownershipR.Ph.LicenseNumber
_________________________________________________________________________________________________

Fullnameofowner HomeaddressPercentageofownershipR.Ph.LicenseNumber
4. Ifapplicationisbeingmadeforacorporation,completetheinformationrequestedbelow:
(a) __________________________________________________________________________________________
Nameandaddressofregisteredagentofthecorporation
(b)Dateofincorporation:__________________________
(c)Isthecorporation’sstock: publiclytraded;or nonpubliclytraded?
Namesandaddressesofallofcersandownersof10percentormoreofstock
(d) President_______________________________________________________________________________________

Nameofofcer HomeaddressPercentageofstockR.P.CerticateNumber
(e) VicePres.______________________________________________________________________________________

Nameofofcer HomeaddressPercentageofstockR.P.CerticateNumber
(f) Secretary_______________________________________________________________________________________

Nameofofcer HomeaddressPercentageofstockR.P.CerticateNumber
(g) Treasurer_______________________________________________________________________________________

Nameofofcer HomeaddressPercentageofstockR.P.CerticateNumber
(h) Others_________________________________________________________________________________________

Nameofofcer HomeaddressPercentageofstockR.P.CerticateNumber
_________________________________________________________________________________________

Nameofofcer HomeaddressPercentageofstockR.P.CerticateNumber
5.
FillintheinformationrequestedbelowforalloftheRegisteredPharmaciststobeemployedatthispharmacy.Listthe
Pharmacist-in-Chargeinline(a)below:
(a) (incharge)______________________________________________________________________________________

FullnameofRegisteredPharmacistHoursemployedperweekOriginalCerticateNumber
(b) _______________________________________________________________________________________________

FullnameofRegisteredPharmacistHoursemployedperweekOriginalCerticateNumber
(c) _______________________________________________________________________________________________

FullnameofRegisteredPharmacistHoursemployedperweekOriginalCerticateNumber
(d) _______________________________________________________________________________________________

FullnameofRegisteredPharmacistHoursemployedperweekOriginalCerticateNumber
(e) _______________________________________________________________________________________________

FullnameofRegisteredPharmacistHoursemployedperweekOriginalCerticateNumber
6. Hours:Thispharmacywillbeopenatotalof_________________hoursperweek.
Openweekdaysfrom__________a.m.to__________p.m.OpenSundaysfrom__________a.m.to__________p.m.
OpenSaturdaysfrom__________a.m.to__________p.m.
Hourstobeclosedformealsorotherexceptions(otherthanmajorU.S.holidays)_________________________________
7. Pharmacist-in-Charge_________________________________________________________________________________

NameAddressHometelephonenumber(includeareacode)
8. Arethereanypendingindictmentsofanynatureoranyallegedviolationsofthelawsgoverningthepracticeofpharmacy,
dispensingnarcotics,alcohol,hypnoticorotherregulateddrugsagainstanyoftheindividualslistedinitemsthree,four,and
veofthisapplication,orhaveanyofthembeenconvictedofanycrimewithinthepast10years?(Attachadditionalsheets
ifneeded.) Yes No
If“Yes,”givedetails._________________________________________________________________________________
___________________________________________________________________________________________________
9. Pasteacopyofyourprescriptionlabelandacopyofyourpoisonlabelinthespacesindicatedbelow:
(Iflabelsarenotavailable,theycanbesupplied
separatelyassoonastheyareavailable.)
10. Pleaseprovidethenameofsupportivepersonnelandallotherunregisteredemployeesconnectedwithprescriptionanddrug
departments.Ifnone,write“None.”(Attachanadditionallistifmorespaceisneeded.)
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
FullnameHomeaddressHoursemployedperweek
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
FullnameHomeaddressHoursemployedperweek
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11. HowmanypharmaciesdoyouoperateinNewJersey?____________(Attachlistofanyadditionalpharmacies.)
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
PharmacynameAddress
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
PharmacynameAddress
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
PharmacynameAddress
12. (a)
Dateuponwhichachangeofownership,movingtoanewlocationoropeningorremodelingofapharmacyisanticipated:
_______________________________________________________________________________________________.
(b) Datepremiseswillbereadyforinspection:(Ifthereadydateforinspectionchangesforanyreason,theBoardof
Pharmacymustbenotied,inwriting,inatimelymanner.)_____________________________________________.
The information requested below, regarding the specications, equipment and facilities of the prescription area, must
be lled in completely.
13. Floordimensionsofthepharmacy.Pleasegivethelengthandwidthincludingtheportionoccupiedbytheprescription
area,butnotincludingstockandstoragerooms. Length:________Width:________
14. Floordimensionsoftheprescriptiondepartmentincludingspaceoccupiedbyxtures.Length:________Width:________
15. Widthofprescriptioncounter,freeofoverhangingshelves:______________Totallengthofcounters:_______________
16. WenowpossessorhaveorderedtheequipmentasoutlinedintheBoardofPharmacyRegulations. Yes No
(Note to purchasers of existing pharmacies: you are to note below the equipment as outlined in the Board of Pharmacy
Regulationswhichisnotnowavailableinyourpharmacy.Atthetimeofyourinspection,youmustshowapurchaseorderfor
themissingequipment.)
17. Theoutlineonpagefourofthisapplicationisatruerepresentationofthedimensionsofthepharmacysettingforth,in
detail,theprescriptiondepartmentxtures.
Afdavit
18. AfdavitA,below,mustbecompletedbytheowner,orapartner,aslistedinitemthreeonpageoneorbyaprincipal
ofceraslistedinitemthreeorfouronpageoneifthepharmacyordrugstoreisownedbyacorporation.Iftheperson
executingAfdavitAisnotalsotheRegisteredPharmacist-in-Chargeofthepharmacyordrugstore,thentheRegistered
Pharmacist-in-ChargemustcompleteAfdavitB.
Each Afdavit must be sworn to before a Notary Public or other authorized ofcer.
Idosolemnlyswearandafrmthattheanswersandstatementsmadeinthisformaretrueandcorrecttothebestofmyknowledge
andbelief,andthattheprescriptionareaofthispharmacyhasalloftheequipmentandfacilitieswiththeexceptionsnotedon
thisapplication,whichwillbeobtainedimmediately,andmeetsallofthespecicationsenumeratedinthe“PrescriptionArea
Regulations”acopyofwhichIhaveseen.Intheeventoflossorbreakageofanyitemontheequipmentlist,itwillbereplaced
promptly.IalsoagreetodisplaythepermitandunderstandthatthepermitisnottransferableandagreetoreturnittotheBoard
uponrequest.IfIshouldmove,sellordiscontinuethispharmacyorifitisdamagedbyreorbyanyotheroccurrenceatany
time,IagreetonotifytheBoardofPharmacyimmediately.Afdavit “A” must be executed on every application.
Afdavit “A”
(seeitem18above)
______________________________________
Nameofpharmacy(ifacorporation,giveexactlegaltitle)
______________________________________
Signature(circletitlebelow)
owner,partner,trustee,receiver,lessee,executor,president,secretary
Subscribedandsworntobeforemethis__________
dayof______________________A.D.__________
Notary’ssignature___________________________
Mycommissionexpires_______________________
Afdavit “B”
(seeitem18above)
______________________________________
SignatureofRegisteredPharmacist-in-Charge
Subscribedandsworntobeforemethis__________
dayof______________________A.D.__________
Notary’ssignature___________________________
Mycommissionexpires_______________________
Affix
SeAl
Here
Affix
SeAl
Here
CorporAtion
SeAl (if Any)
To Notary Public: Please make sure that the person taking the oath has read all of item 18.
click to sign
signature
click to edit
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signature
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signature
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signature
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Drawanoutlineoftheoorplanofthepharmacy,includingtheprescriptionareaandstockrooms,onthispage.If
thelengthoftheroomislessthan72feet,considereachsquareasmeasuringtwofeetoneachside.Ifthelength
ofthestoreexceeds72feet,considereachsquareequivalenttofourfeetoneachside.Indicatethespaceallottedto
eachdepartmentaccordingtoscale.Useinkwhenmakingthesketch,ifpossible.Pleaseusearulerinmakingthe
drawing.
Outline prescription area xtures in detail with dimensions.
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
Board of Pharmacy
124 Halsey Street, 6th Floor, PO Box 45013,
Newark, NJ 07101
(973) 504-6450
Afdavit “C”
All questions must be answered and forwarded to the Board of Pharmacy together with theApplication for Renewal of
RegistrationandPermittoOperateaPharmacy.NorenewalpermitwillbeissuedwithoutasignedanddatedAfdavit‘’C,”
whichwillbeafxedtoandbecomeapartoftheApplicationforRenewalofRegistrationandPermittoOperateaPharmacy.
Answerallofthequestionscompletely.
Pleasecheck“Yes’’or‘’No.”
1. Doesanyphysician(s),orotherperson(s)authorizedtowriteprescriptionsintheStateofNewJersey,possessanynancial
interest,directorindirect,inthepharmacy?  Yes No
2. Doesanyphysician(s),orotherperson(s)authorizedtowriteprescriptionsintheStateofNewJersey,possessanylease-
holdinterest,directorindirect,inthepharmacy? Yes No
3.Doesanyphysician(s),orotherperson(s)authorizedtowriteprescriptionsintheStateofNewJersey,ownorpossessany
interest,directorindirect,inthebuildinginwhichthepharmacyislocated? Yes No
4. Arethereanyoutstandingloans,toorfrom,physician(s)orotherperson(s)authorizedtowriteprescriptionsintheStateof
NewJersey? Yes No
5. Iftheanswertoanyoftheaboveis“Yes,”kindlyanswerthefollowingquestions.Pleasetypeorprintclearly.
a. Isthephysician(s)orotherperson(s)practicinginthetradingareaofthispharmacy? Yes No
b. Nameandaddressofthephysician(s)orotherperson(s):
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
c. Extentanddescriptionofthenancialinterest.Pleaseprovideafullexplanation:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
_____________________________________________________________________________________________
______________________________________________________________________________________________
IcertifythatthestatementsmadebymeonAfdavit“C”aretrue.Iamawarethatifanyofthestatementsmadebymeare
willfullyfalse,Iamsubjecttopunishment.
_____________________________________________________________________________________________________

Nameofpharmacy(Ifacorporation,givetheexacttitle.)
__________________________________________________________________________________________

DateSignatureofownerorofcer
Title(checkone): Owner Partner President Secretary Treasurer
click to sign
signature
click to edit
Afdavit Regarding Internet and/or Mail Order Pharmacy Activity
ThismatterwasopenedtotheNewJerseyStateBoardofPharmacybyapplicationof__________________________
____________________________to operate a pharmacy in the State of New Jersey.Theapplicant,whomayengagein
Internetand/ormailorderpharmacyactivityunderaretailpermitgrantedpursuanttothesignatureonthisAfdavit,hasagreed
tothefollowingconditionspriortocommencingeitherorbothoftheabove-listedservices:
1. __________________________________________isherebygrantedaretailpermittooperateapharmacyintheStateof
NewJersey,subjecttothefollowingongoingconditionssetforthinparagraphs2through4below.
2. __________________________________________.(“applicant”)shallobtaintheNationalAssociationofStateBoards
ofPharmacyVeriedInternetPharmacyPracticeSiteCerticationpriortoengaginginInternetoronlinedispensing.
3. TheapplicantshallmakeallreasonableeffortstoensurethatallprescriptionsreceivedviatheInternet,orbymail,are
valid,towit,thereexistsaprescriber-patientrelationshipandthatareasonableandprudentpharmacistwouldbelievethat
thepatienthasbeenphysicallyexaminedbytheprescriberorthecollaboratingphysician.Theapplicantshallnotaccept
anyprescriptionfordispensingwhereheknowsorshouldhaveknownthattheprescriptionhasbeenwrittenpursuantto
anonlinediagnosisorsurveybyaprescriber.
4. TheapplicantshallnotactasafacilitatorofprescriptionsbeingtransferredbytheInternetorbymailtoanypharmacy
inoroutsideoftheUnitedStatesthatheknowsorshouldhaveknowndispensesinviolationoftheconditionssetforthin
Paragraph3ofthisAfdavit.Thisparagraphshallnotprecludetheroutinetransferoftheprescriptionasrequestedbythe
patientasauthorizedbyStateandfederallaw.
Afdavit of Applicant
I, ____________________________________________, agree being duly sworn, depose and say under penalty of false
statement,Iamthepartydescribedasabove;thattheinformationgiveninthisAfdavitandsubmittedmaterialscontainnowillful
misrepresentationsandthattheinformationistrueandcomplete.Iunderstandthatshouldaninvestigationatanytimedisclose
otherwise,Imayfacelegalsanctions.IunderstandthatinsigningthisAfdavit,Iamconsentingtoanyreasonableinquiry
thatmaybenecessarytoverifytheinformationIhaveprovidedinthisdocument.
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Notary’sCommissionExpires:______________________
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Pharmacy Permit Application (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 15 August 2020

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