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

Reinstatement Application NON-RESIDENT PRESCRIPTION DRUG OUTLET (OSP)

Fee: $355

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 Non-Resident Prescription Drug Outlet (OSP) 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 verification of the current pharmacy licensed issued by the state of residence. You may submit the detailed online screen print from the State Board of Pharmacy webpage. The screen print must list the facility address and must address and discipline (if applicable). • If the license has been expired two (2) years or more, include a copy of the most recent inspection conducted within the past two (2) years by the non-resident pharmacy by either its resident state board of pharmacy or the National Association of Boards of Pharmacy Verified Pharmacy Program. • 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 an OSP registration.  Enclose the fee with your application and continue to PART 2.

$355

—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.

$450

—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: Change of Pharmacist Manager Previous Pharmacist Manager: License Number: State: Last date employed as Pharmacist Manager:

$35

$35

Total Fee: $

Non-Resident Prescription Drug Outlet (OSP) Reinstatement

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PART 2 1.

Pharmacy Name:

2.

Colorado Registration Number:

3.

Pharmacy Business License Number – State of Residence:

4.

Federal Employer Identification Number (FEIN):

5.

Facility Address:

Date Registration Expired:

Street & Number

6.

Daytime Telephone:

7.

E-mail Address:

8.

Pharmacist Manger:

City

State

Zip Code

Fax Number:

License Number:

State:

Date Managership Began:

9.

Is this pharmacy certified by NABP’s Verified Internet Pharmacy Practice Sites (VIPPS) program?

YES

NO

10.

Has the pharmacy dispensed and delivered prescriptions to consumers residing in Colorado since the registration has expired?

YES

NO

11.

Indicate the type of ownership and enter the required information (attach additional pages if necessary): Individual, trustee, or receiver Name: Partnership Name: Corporation Name: States where incorporated: Date of last biennial report (if required by state where incorporated): Corporate Officers (attach additional pages if necessary): Name

Non-Resident Prescription Drug Outlet (OSP) Reinstatement

Title

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Social Security Number

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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

PART 4 The undersigned hereby states: • • • • • • • •

All information contained in this application for a Non-resident Prescription Drug Outlet (OSP) registration is true and correct; He/she has read and is familiar with all the provisions of the law relative to the conduct of a Non-resident Prescription Drug Outlet in Colorado; Such provisions of the law will be faithfully observed; The Non-resident Prescription Drug Outlet complies with Section 12-42.5-130(1)(b) of the Colorado Revised Statutes (C.R.S.) The pharmacy has reported annually to the Board the location, names, and titles of all principle entity officers and all pharmacists who are dispensing drugs or devices to residents of this state; The pharmacy will submit to the Colorado State Board of Pharmacy, within 30 days, changes to the location, names, and titles of all principle entity officers and all pharmacies who are dispensing drugs or devices to residents of this state; The pharmacy is in and will remain in compliance with Colorado’s Electronic Prescription Drug Monitoring (PDMP) reporting requirements pursuant to § 12-42.5-407, C.R.S. and Board rule 23.00.00; and Pursuant to Board rules 3.00.20 and 3.00.21, the pharmacy does not dispense drugs to residents of Colorado in such quantity or in any situation where the licensee or registrant knows or reasonably should know said drug has no recognized medical utility or application, specifically, if the pharmacist knows or should have known that the order for such drug was issued on the basis of an internet-based questionnaire, an internet-based consultation, or a telephonic consultation, all without a valid preexisting patient-practitioner relationship.

I certify that an inspection has been conducted of the applicant by the resident Pharmacy Board. If the license has been expired two (2) years or more, include a copy of the most recent report of inspection conducted within the past five (5) years by the resident Pharmacy Board. 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.

Pharmacist Manager’s Signature:

Non-Resident Prescription Drug Outlet (OSP) Reinstatement

Date:

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