Application For Authority To Dispense Drugs - Nevada State Board Of Pharmacy (Page 2 of 4) in pdf

NEVADA STATE BOARD OF PHARMACY

431 W Plumb Lane

Reno, NV 89509

(775) 850-1440

APPLICATION FOR AUTHORITY TO DISPENSE DRUGS

Registration Fee: $300.00

(non-refundable money order or cashier s check

only)

New Dispensing Location o

Address Change o (Requires Fee and New Application)

o Yes

o No

Do you, as a dispensing practitioner or in conjunction only with other practitioners, wholly own your practice?

I will be dispensing o controlled substances o dangerous drugs or o both. Must check a box.

If you dispense controlled substances, a controlled substance registration and DEA is required for the address

listed on this application.

First:

Middle:

Last:

Degree:

Practice Name (if any):

Nevada Address:

Suite #:

(This must be a practicing Nevada address, we will not issue a license to a home address or to a PO Box only)

Sex: o M or o F

PO Box:

SS#:

E-mail address:

Date of Birth:

City:

State: NV

Zip Code:

Nevada Work Telephone:

Nevada Fax:

Practitioner License Number:

Specialty:

You must be licensed with your respective BOARD before we will process this application.

Been diagnosed or treated for any mental illness, including alcohol or substance

Yes No

abuse, or physical condition that would impair your ability to perform the essential

functions of your license?.................................................................................................................... o o

o o

1. Been charged, arrested or convicted of a felony or misdemeanor in any state?

2. Been the subject of an administrative action whether completed or pending in any state?................ o o

3. Had your license subjected to any discipline for violation of pharmacy or drug laws in any state?.... o o

If you marked YES to any of the numbered questions (1-3) above, include the following information & provide

documentation:

Board Administrative

State

Date:

Case #:

Action:

Criminal

State

Date:

Case #:

County

Court

Action:

The undersigned practitioner, licensed to practice his or her profession in the State of Nevada, applies to the Board of Pharmacy for

authorization to dispense, for profit, controlled substances or dangerous drugs or both, to his or her own patients, in the manner allowed

and as required by Nevada and Federal law.

I hereby certify that the answers given in this application are true and correct to the best of my knowledge. I understand that the

approval of this application provides me alone with the authority to dispense controlled substance or dangerous drugs or both to my

own patients at the address stated on the application. I further understand that I may not delegate this authority to any other person. I

further agree to abide by all statutes, rules or regulations governing practitioner dispensing and understand that a violation of any such

statute, rules or regulations may be grounds for suspension or revocation of this permit of authorization.

Original Signature, no copies or stamps accepted.

Date

ÿBoard Use Only

Received:

Amount:

Entity#

Application For Authority To Dispense Drugs - Nevada State Board Of Pharmacy Page 2

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