Division of Professions and Occupations Office of Licensing—Pharmacy 1560 Broadway, Suite 1350 Denver, CO 80202 (303) 894-7800 / Fax (303) 894-7693 www.dora.colorado.gov/professions
Application for Registration LIMITED LICENSE (LTD)
New Registration: $50 / Transfer Ownership: $25 Change Location: $125 Change Name: $35 Fees may be paid by a check or money order drawn in U.S. dollars on a U.S. bank and made payable to State of Colorado
(This application must also be used for changes to existing registrations.) APPLICANT INSTRUCTIONS Basic Requirements. Requirements for registration are outlined in Section 12-42.5-117 of the Colorado Revised Statutes, (C.R.S.) and the Board rules. Both are available online at: www.dora.colorado.gov/professions/pharmacy.
Limited License registrations are issued only to the following types of organizations: • A non-profit humane society incorporated in the State of Colorado and in business for at least five (5) years. • A government-operated animal control agency.
About the Application. This application is to be completed by you and returned to the Office of Licensing. All questions on the application are mandatory, and all supporting documents must be submitted with the application. You may copy as many forms as needed; however, each form submitted must be completed in original ink or typed. Be sure to keep a copy of the completed application for your records. Application Expiration. Your application will be kept on file for one (1) year from date of receipt in the Division. Your file and all supporting documentation will be purged if you do not submit required documents and complete your application process in one year. You will need to resubmit a new application packet and fee after that time. Disclosure of Addresses. Consistent with Colorado law, all addresses and phone numbers on record with the Division are public record and must be provided to the public when requested. It is your responsibility to keep your contact information current in our system. Your email address is not open to public record, but must be provided in this application. Any requests for additional information, license information and renewal notices will be emailed to the email address on record. If your email address is not current, it is possible you will not receive important information from the Division. You can change your contact information online by using Online Services at: www.dora.colorado.gov/professions/onlineservices. Checking Your Application Status. Visit Online Services at: www.dora.colorado.gov/professions/onlineservices to track your application from the date we log it in our database to the date your license is available for printing. Please allow us enough time to receive the application through the mail and enter your application into our database before you check the website. We recommend waiting at least 10 business days from date of mailing before checking the status of your application. Registration Expiration Grace Period for New Applicants. All new applicants who are issued a registration within 120 days of the upcoming renewal expiration date will be issued a registration with the subsequent expiration date. For example, registration issued between July 4, 2016 and October 31, 2016 will reflect an expiration date of October 31, 2018. Registrations issued prior to July 4, 2016 will reflect an expiration date of October 31, 2016 and must renew in the upcoming renewal period.
All limited licenses registrations expire on October 31 of even-numbered years and must be renewed to continue practicing.
Printing your Registration upon Approval. DORA is no longer printing and mailing wallet cards as registrations. To print your wallet card registration in its current status, login to your Online Services account at: www.dora.colorado.gov/professions/onlineservices and select “Print Your License” in the left-hand menu.
Applicant: Keep this page for your records.
06/2015
Division of Professions and Occupations Office of Licensing—Pharmacy 1560 Broadway, Suite 1350 Denver, CO 80202 (303) 894-7800 / Fax (303) 894-7693 www.dora.colorado.gov/professions
Application for Registration LIMITED LICENSE (LTD)
New Registration: $50 / Transfer Ownership: $25 Change Location: $125 Change Name: $35 Fees may be paid by a check or money order drawn in U.S. dollars on a U.S. bank and made payable to State of Colorado
APPLICANT CHECKLIST For a new Limited License registration: Submit a completed application and supporting documentation if required. Return the completed application and all supporting documentation to the Office of Licensing.
An official or veterinarian of the animal shelter or animal control agency must complete the application. This individual assumes responsibility for compliance with state and federal laws, rules, and regulations pertaining to controlled substances.
Enclose the non-refundable application-processing fee. Fees may be paid by check or money order drawn in U.S. dollars and made payable to State of Colorado. All fees are non-refundable and subject to change every July 1. Attach a copy of your current DEA registration.
The shelter or agency shall obtain the appropriate DEA registration from the Drug Enforcement Administration, 12154 E. Easter Avenue, Centennial CO 80112; telephone (800) 326-6900; website: www.deadiversion.usdoj.gov.
Humane Societies must also: Submit a Certificate of Good Standing from the Colorado Secretary of State. Animal Control Agencies must also: Identify your governmental relationship and briefly explain the function of your unit. Follow the instructions in Part 2 of the application. To change the business name or location of an existing Limited License registration: Submit a completed application and supporting documentation if required. Return the completed application and all supporting documentation to the Office of Licensing.
An official or veterinarian of the animal shelter or animal control agency must complete the application. This individual assumes responsibility for compliance with state and federal laws, rules, and regulations pertaining to controlled substances.
Enclose the non-refundable application-processing fee.. Fees may be paid by check or money order drawn in U.S. dollars and made payable to State of Colorado. All fees are non-refundable and subject to change every July 1. Return your completed application packet and all supporting documentation to: Division of Professions and Occupations Office of Licensing—Pharmacy 1560 Broadway, Suite 1350 Denver, CO80202
Applicant: Keep this page for your records.
06/2015
Division of Professions and Occupations Office of Licensing—Pharmacy 1560 Broadway, Suite 1350 Denver, CO 80202 (303) 894-7800 / Fax (303) 894-7693 www.dora.colorado.gov/professions
Application for Registration LIMITED LICENSE (LTD)
New Registration: $50 / Transfer Ownership: $25 Change Location: $125 Change Name: $35 Fees may be paid by a check or money order drawn in U.S. dollars on a U.S. bank and made payable to State of Colorado
The content of this application must not be changed. If the content is changed, the applicant may be referred to the Colorado State Attorney General’s Office for violation of Colorado law. If additional pages are attached to respond to requested information in any part of the application, please indicate the number of the item to which you are responding.
PART 1. Select from the following: I am submitting an application for new Limited License registration. Enclose fee with your application and continue to Part 2. - OR I am reporting a Transfer of Ownership for a current registration. Previous owner name: Effective date of new ownership: Enclose fee with your application and continue to Part 2. - OR I am reporting a change in existing registration as follows: (select all that apply) Change of Business Location Previous location: Effective date of location change: Change of Business Name Previous business name: Effective date of new name: Total Fee:
$50
$25
$125
$35
$
PART 2. 1. Colorado Registration Number:
If this is a new registration, leave blank.
2. Business Name: List all trade names or DBA names used by business:
3. Federal Employer Identification Number (FEIN): 4. DEA Registration Number: 5. Address: Street & Number
City
6. Daytime Telephone:
State
Zip Code
Fax Number:
7. E-mail Address: 8. Designated Contact Person for this Site: Full name and title: Telephone number: OFFICE USE ONLY Limited License
Length of service with applicant: REGISTRATION NUMBER: ________________________ Page 1 of 2
DATE ISSUED: ______________________________ 06/2015
Division of Professions and Occupations Office of Licensing—Pharmacy 1560 Broadway, Suite 1350 Denver, CO 80202 (303) 894-7800 / Fax (303) 894-7693 www.dora.colorado.gov/professions
Application for Registration LIMITED LICENSE (LTD)
New Registration: $50 / Transfer Ownership: $25 Change Location: $125 Change Name: $35 Fees may be paid by a check or money order drawn in U.S. dollars on a U.S. bank and made payable to State of Colorado
9. Our organization is: Humane Society Attach a copy of Certificate of Good Standing from the Colorado Secretary of State. Animal Control Agency Identify your governmental relationship and briefly explain the function of your unit:
10. Staff Veterinarian(s): List below the name, address, Colorado Veterinarian license number, and DEA registration number of any veterinarian(s) on the staff of the applicant, or who will be involved in the training of the applicant’s personnel. Name
Colorado License No.
Address
DEA Registration No.
PART 3. 11. Background Questions: If the answer to any question is YES, attach additional pages and explain fully. A. Has the applicant or any person identified in this application been convicted under any federal, state, or local law relating to drug samples, drug manufacturing, drug dispensing, wholesale or retail drug distribution, or distribution of controlled substances?
YES
NO
B. Has the applicant or any person identified in this application had any criminal or civil conviction under federal or state laws?
YES
NO
C. Has any person identified in this application had any license or registration to manufacture, dispense, or distribute legend drugs or controlled substances suspended or revoked?
YES
NO
D. Has any person identified in this application been convicted of a felony or pled nolo contendere to a felony under any federal, state, or local law?
YES
NO
E. Has any registration or license to manufacture or distribute legend drugs and/or controlled substances currently or previously held by applicant ever been suspended or revoked?
YES
NO
Per § 12-4-104(13)(a), C.R.S., any applicant who, under oath, supplies false information to an agency in an application for a license, commits perjury in the second degree as defined in § 18-8-503, C.R.S. In accordance with §§ 18-8-503 and 18-8-501(2)(a)(l), C.R.S., false statements made herein are punishable by law. THIS APPLICATION COMPLETED BY: Signature:
Date:
Name: Limited License
Title: Page 2 of 2
06/2015
Division of Professions and Occupations Office of Licensing—Pharmacy 1560 Broadway, Suite 1350 Denver, CO 80202 (303) 894-7800 / Fax (303) 894-7693 www.dora.colorado.gov/professions
Application for Registration LIMITED LICENSE (LTD)
New Registration: $50 / Transfer Ownership: $25 Change Location: $125 Change Name: $35 Fees may be paid by a check or money order drawn in U.S. dollars on a U.S. bank and made payable to State of Colorado
Recommended Protocols for Use of Sodium Pentobarbital in Animal Euthanasia
The following are recommended protocols for complying with § 12-42.5-117(12), C.R.S. These recommendations apply to the purchase and use of sodium pentobarbital alone or in combination with other drugs for animal euthanasia. Records Licensee shall maintain complete and accurate records of receipt, use, loss, or waste for at least two years after the date of last activity. A complete inventory of all controlled substances on hand shall be conducted at least every two years. This inventory shall be recorded and maintained at the facility. Licensee shall use Drug Enforcement Administration (DEA) Form 222 to obtain sodium pentobarbital alone from suppliers. Licensee shall obtain controlled substances only from suppliers possessing a valid DEA registration and those suppliers registered with the Board of Pharmacy. All records pertaining to controlled substances must be readily available and retrievable at any time upon demand by either a pharmacy board inspector or representative of the DEA. Training A licensed veterinarian provides training to staff including but not limited to the following areas: 1. 2. 3. 4. 5.
Description of the pharmacological action of the drug Route of administration depending on the animal Operation of equipment Nomenclature of measurements On-the-job demonstration
Security Limited access to controlled substances shall be maintained. Drugs should be stored in security locked cabinets or a safe bolted to the floor. A list of individuals designated for access and use of the drugs should be maintained. Drugs must be stored at the address registered with the DEA. Applications An official or veterinarian of the animal shelter or animal control agency must complete the application to the Board of Pharmacy. This individual assumes responsibility for compliance with state and federal laws, rules, and regulations pertaining to controlled substances. DEA Registration The shelter or agency shall obtain the appropriate DEA registration from the Drug Enforcement Administration, 12154 E. Easter Avenue, Centennial, CO 80112; telephone (800) 326-6900; website: www.deadiversion.usdoj.gov.
Limited License Protocols
06/2015
