Free 47228.FH11 - Indiana

APPLICATION FOR LICENSURE AS A WHOLESALE DRUG DISTRIBUTOR
State Form 47228 (R3 / 2-06) Approved by State Board of Accounts, 2006

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INDIANA BOARD OF PHARMACY PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2067 E-mail: [email protected]

NOTICE:

A copy of your: 1. VAWD accreditation, or 2. Other Board-approved accreditation must be submitted with the application; otherwise, the application will not be processed. FOR OFFICE USE ONLY

Application fee License Number

Date paid (month, day, year) Date issued (month, day, year)

Receipt number

DO NOT WRITE ABOVE THIS LINE
BUSINESS INFORMATION
Legal name of business All trade / business names used by this entity

FACILITY INFORMATION
Principal facility address (number and street, city, state, and ZIP code) Telephone number Fax number County

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E-mail address Principal mailing address (number and street, city, state, and ZIP code)

Website (if applicable) County

ACCREDITATION
Name of accreditation Accreditation number Date of accreditation (month, day, year) Expiration date of accreditation (month, day, year)

QUESTIONS 1. Has the applicant or any of the applicants employees or associates had a disciplinary action taken by the federal or state government of any license(s) held by any employee or associate? 2. Has the applicant or any of the applicants employees or associates ever been convicted of a felony? 3. Is any action pending on any of the above? Yes Yes Yes No No No

AFFIRMATION 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 contact person Date signed (month, day, year)

Printed name of contact person

Title of contact person