State Form 47228 - Application For Indiana Wholesale Drug Distributor License

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FOR OFFICIAL USE ONLY
APPLICATION FOR INDIANA
Health Professions Bureau
Indiana Board of Pharmacy
Application fee
WHOLESALE DRUG DISTRIBUTOR
LICENSE
Date fee paid
Date application received
State Form 47228 (R2 / 7-02)
Approved by State Board of Accounts, 2002
Receipt number
C.M.
* The request for Social Security number(s) is MANDATORY according to IC 4-1-8-1.
Legal name of business
Full facility address (number and street, city, state, ZIP code)
Mailing address of facility (if different from business name)
County
Telephone number
(
)
Name of contact person
Telephone number
(
)
Address of contact person
Email address
Name of person responsible for the operation of the facility
Telephone number
(
)
Address of person responsible for the operation of the facility
List all trade or business names used by the corporation or licensee
List name(s) and Social Security number(s) * of the owner(s) and/or operator(s) of the licensee. Indicate the type of ownership. Partnerships - give the name of each partner
and address of each partnership; Corporations - give the name and title of each corporate officer and director, the corporate name(s), name and address of the parent company
(if any), and the state of incorporation; Sole Proprietorships - give the name of the sole proprietor and the name and address of the business entity. (attach a separate sheet if
more space is needed)
Type of operation (check all that apply)
Full Service Wholesaler
Retail or Hospital Pharmacy Conducting Wholesale Distribution
Distributors' Warehouse
Manufacturer
Private-label Distributor
Contract Distributor
Chain Drug Warehouse
Repacker
Own-label Dristributor
Jobber or Broker
Independent Wholesale Drug Trader
Medical Gas Seller/Distrubutor/Relabeler
Manufacturers' Warehouse
Other (specify)
Sells drugs to: (check all that apply)
Community Pharmacies
Veterinarians
Physicians or Other Practitioners
Hospital Pharmacies
Wholesalers
Other (specify)
Types of drugs distributed (check all that apply)
Controlled Substances
Non-prescription Drugs
Non-controlled Prescription Drugs
DEA Number ________________________
Other (specify)
List and explain if an answer to any of the questions below is "Yes" by attaching a separate letter explaining the situation(s)
in detail.
Have any of the applicant(s) and/or managers had any convictions relating to drug samples, whole-
Yes
No
sale or retail distribution, or distribution of controlled substances?
Have any of the applicant(s) and/or managers had any felony convictions?
Yes
Yes
No
No
Have any of the applicant(s) and/or managers had a suspension or revocation by the federal or
Yes
No
state government of any license held by the applicant(s) for the manufacturer or distribution of any
drugs, including controlled substances?
Is any action pending on any of the above?
Yes
No
I do solemnly swear or affirm, under the penalties of perjury, that I am the person authorized to sign this application for licensure
and that statements made are true and correct in all respects.
Signature of owner or corporate officer
Date signed (month, day, year)
Title of owner or corporate officer
Social Security number

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