Division of Professions and Occupations Colorado State Board of Pharmacy 1560 Broadway, Suite 1350 Denver, CO 80202 (303) 894-7800 / Fax (303) 894-7693 www.dora.colorado.gov/professions

Notification of Closure NON-RESIDENT PHARMACY (OSP) OUT-OF-STATE WHOLESALER (WHO) No fee

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Complete this form upon closure of a Non-Resident Pharmacy (OSP) or Out-of-State Wholesaler (WHO).

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Return the completed form and any required documentation to Division of Professions and Occupations, Office of Licensing—Pharmacy, 1560 Broadway, Suite 1350, Denver, Colorado, 80202. No fee is required.

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AFTER THE PHARMACY OR WHOLESALER IS CLOSED, THE REGISTRATION IS VOID.

PHARMACY/WHOLESALER INFORMATION Pharmacy or Wholesaler Name: Date of Closure: Pharmacy or Wholesaler Physical Address:

Colorado Registration Number: Daytime Telephone Number: (

OSP WHO

)

Street: City, State, Zip:

ATTESTATION I state under penalty of perjury in the second degree, as defined in Section 18-8-503 of the Colorado Revised Statutes (C.R.S.), that the information contained in this Notification of Closure is true and correct to the best of my knowledge.

Signature

Date

(OSP: Last pharmacist manager of record; WHO: Last designated representative of record)

OSP/WHO Notification of Closure

06/2015