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

Reinstatement Application OTHER OUTLET Reinstatement: $163

To reinstate your Other Outlet registration: ♦

Submit a completed application and supporting documentation if required. Return the completed application and all supporting documentation to the Office of Licensing.

♦

Enclose the non-refundable application processing fee. Fees may be paid by a 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 two (2) copies of completed Other Outlet Protocol Form. All applicable supplements referenced in the completed form must also be submitted. 

The protocols must be typed on forms supplied by the Board. A Microsoft Word fill-in form is available on our website at: www.colorado.gov/dora/Pharmacy. 

Two copies of all protocols and supplements are required for application processing. If two copies are not submitted, the facility will be charged a copy fee of $0.25 per page. This fee must be paid prior to approval.

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. I am submitting a reinstatement application for Other Outlet registration.  Enclose fee with your application and continue to Part 2.

$163 Total Fee:

$

PART 2. 1. Colorado Registration Number:

Date Registration Expired:

2. Business Name: List all trade names or DBA names used by business:

3. Federal Employer Identification Number (FEIN): 4. Mailing Address: Street & Number

City

State

Zip Code

City

State

Zip Code

5. Physical Address (if different): Street & Number

6. Daytime Telephone:

Fax Number:

7. E-mail Address: 8. Type of Organization(if your facility does not fall into one of these categories, you are not eligible for registration as an Other Outlet Acute Treatment Unit Jail Medical clinic operated by a hospital County health department Community or rural health clinic (Including Federally Qualified Health Centers)

Other Outlet Reinstatement

Telepharmacy School, college or university student/faculty health service Inpatient Hospice Hospital, not currently operating a prescription drug outlet Family planning clinic Ambulatory surgery center

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9.

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

YES

NO

10. Type of Ownership (check one and complete information as applicable): Individual, Trustee, or Receiver Full name of Owner/Trustee/Receiver: Individual’s Social Security Number: Partnership Name of Partnership: Federal Employer Identification Number: List full name and Social Security Number of each partner (attach additional pages if necessary):

Corporation ATTACH A STATEMENT to this application listing the following: Name, Social Security Number, and title of each corporate officer and director Name of parent company, if any Corporate names and state of incorporation Federal Employer Identification Number of the business entity Date of last annual report to Colorado Governmental Entity Name of Director: Name of Governmental Entity: 11. Operational Information: Days and Hours of operation of the facility: Days and Hours when a responsible person with access to the drugs and records is on-site to permit the Board of Pharmacy to inspect the facility and drugs and review appropriate records: Name and title of contact person at the facility: Consultant Pharmacist: This is the person responsible for providing written, board-approved protocols for dispensing by non-pharmacists. The Consultant Pharmacist must also perform inspections of the Other Outlet to assure compliance with the protocols, as well as any other duties explained in the Board’s rules. Name: Place of practice (name): Business address: Home address: Telephone numbers (with area code): Work:

Colorado License Number:

Home:

Signature of Consultant Pharmacist:

Other Outlet Reinstatement

Date:

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PART 3. 12. 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 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

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:

Date:

Name:

Other Outlet Reinstatement

Title:

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