Affidavit for a New Pharmacy¹

I, _______________________________________, the ________________________  (Title of officer, official, partner, or other position) of _____________________________  (Corporation, partnership, or sole proprietor), doing business as ______________________________________________ (Store name) at _______________________________ (Number and Street), _____________________ (City) _______________________ (State) ___________________ (Zip Code), hereby certify that said store was issued a pharmacy permit No. __________________ by the _____________________________ (Board of Pharmacy or Licensing Agency) of the State of ________________________ on _________________________ (Date).

This statement is submitted in order to obtain a Drug Enforcement Administration registration number. I understand that if any information is false, the Administration may immediately suspend the registration for this store and commence proceedings to revoke under 21 U.S.C. 824(a) because of the danger to public health and safety. I further understand that any false information contained in this affidavit may subject me personally and the above-named corporation/partnership/business to prosecution under 21 U.S.C. 843, the penalties for conviction of which include imprisonment for up to four (4) years, a fine of not more than $30,000.00 or both.

_________________________________________________________

Signature (Person who signs Application for Registration)

State of ___________________________________

County of __________________________________________

Subscribed to and sworn before me this ________ day of ____________, 20______.

____________________________________________

Notary Public