Division of Professions and Occupations Office of Licensing—Pharmacy (303) 894-7800 / Fax (303) 894-7693 www.dora.colorado.gov/professions

Reinstatement Application LIMITED LICENSE (LTD)

Fee: $69

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.

To reinstate a Limited License registration, you must: •

• • •

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. Return the completed application, any required documentation, and the reinstatement fee to: Division of Professions and Occupations, Office of Licensing, 1560 Broadway, Suite 1350, Denver, CO 80202.

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 a reinstatement application for a Limited License registration.  Enclose the fee with your application and continue to PART 2.

$69

—AND/OR— I am reporting a Transfer of Ownership for a current registration. Previous Owner Name: Effective date of New Ownership:  Enclose the fee with your application and continue to PART 2.

$25

—AND/OR— I am reporting a change to an existing registration as follows (select all that apply): Change of Business Location Previous Location:

$125

Change of Business Name Previous Business Name: Effective date of New Name:

$35

Total Fee: $ PART 2 1.

Colorado Registration Number:

2.

Business Name:

Date Registration Expired:

List all trade names or DBA names used by business:

3.

Federal Employer Identification Number (FEIN):

4.

DEA Registration Number:

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5.

Address: Street & Number

6.

Daytime Telephone:

7.

E-mail Address:

8.

Designated Contact Person for this Site:

City

City

City

Fax Number:

Full Name and Title: Telephone Number:

Length of Service with Applicant:

9.

Has the facility possessed or administered prescription drugs or controlled substances since the registration has expired?

10.

Our organization is:

YES

NO

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:

11.

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

Address

Colorado License No.

DEA Registration No.

PART 3 Background Questions: If the answer to any question is YES, attach additional pages and explain fully.

12. 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 disciplined, 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 disciplined, suspended or revoked?

YES

NO

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PART 4 Per Section 12-4-104(13)(a) of the Colorado Revised Statues (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 § 18-8503, C.R.S.. In accordance with §§ 18-8-503 and C.R.S. 18-8-501(2)(a)(l), C.R.S., false statements made herein are punishable by law. THIS APPLICATION COMPLETED BY: Signature: Name:

Limited License Reinstatement

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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

09/2016