ap-MedicalGases - APPLICATION FOR A PERMIT UNDER CHAPTER...

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APPLICATION FOR A PERMIT UNDER CHAPTER 499, FLORIDA STATUTES Florida Department of Health - Board of Pharmacy, Drugs, Devices, and Cosmetics P.O. Box 6320 - Tallahassee, Florida 32314-6320 (850) 245-4292 This application form provides information as required by the Florida Drug and Cosmetic Act, Chapter 499, Florida Statutes. Only a completed application signed by the authorized representative of the applicant will be processed. Additional information may be required for an application to be considered complete. This application must be filled out in its entirety. Failure to do so will result in a delay in the permitting process. APPLICATION TO BE TYPED OR PRINTED WITH INK Type of permit(s) requested (mark all that apply). The applicant can apply for multiple permits under one application if each permit requested is at the same physical location and the same permit name. This application cannot be used to apply for a Prescription Drug Wholesaler, Prescription Drug Wholesaler/Broker Only, or Out-of-State Prescription Drug Wholesaler permit; use form DH 2124 MANUFACTURERS RESTRICTED PERMITS Prescription Drug Manufacturer Restricted Prescription Drug Distributor - Health Care Entity Non-Resident Prescription Drug Manufacturer Restricted Prescription Drug Distributor - Charitable Organization Over-the-Counter Drug Manufacturer Restricted Prescription Drug Distributor - Reverse Distributor Compressed Medical Gases Manufacturer Restricted Prescription Drug Distributor - Destruction Prescription Drug Repackager Restricted Prescription Drug Distributor - Government Programs Device Manufacturer Restricted Prescription Drug Distributor - Institutional Research Cosmetic Manufacturer OTHER CATEGORIES WHOLESALERS Complimentary Drug Distributor Veterinary Prescription Drug Wholesaler Veterinary Legend Drug Retailer Compressed Medical Gases Wholesaler Medical Oxygen Retailer Retail Pharmacy Wholesaler Freight Forwarder Limited Veterinary Prescription Drug Wholesaler SEE REVERSE SIDE FOR APPLICATION FEES 1 NAME OF APPLICANT (name in which company is doing business; this is the name in which the permit will be issued; limit to 41 characters) 2 APPLICANT ADDRESS (physical location of establishment - this address should be reflected on all sales invoices and shipping documentation) 3 SUITE NUMBER 4 CITY 5 STATE 6 ZIP - 7 COUNTY 8 AREA CODE & TELEPHONE NUMBER -- 9 * NORMAL OPERATING HOURS 10 * PROVIDE AN EMAIL ADDRESS WHERE REGULATORY UPDATES CAN BE SENT M: AM PM TO : AM PM TU : AM PM TO : AM PM W: AM PM TO : AM PM 11 * FACSIMILE NUMBER WHERE REGULATORY UPDATES CAN BE SENT TH : AM PM TO : AM PM F: AM PM TO : AM PM * NOTIFY THE DEPARTMENT IN WRITING OF ANY UPDATES 12 MAILING ADDRESS (if different from physical location; this is where the renewal application and other official information will be sent by the department) 13 SUITE NUMBER 14 CITY 15 STATE 16 ZIP - 17 EMERGENCY CONTACT PERSON (an individual with your company that the department can contact, if necessary, after normal business hours) NAME (Last, First, MI) RESIDENCE PHONE (Area Code & Number) RESIDENCE ADDRESS POSITION/TITLE CITY
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This note was uploaded on 02/11/2011 for the course NURSING n1101 taught by Professor Anton during the Spring '11 term at Valencia.

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ap-MedicalGases - APPLICATION FOR A PERMIT UNDER CHAPTER...

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