Affidavit for Transfer of a Pharmacy¹

I, _______________________________________, the _________________________  (Title of officer, official, partner, or other position) of _______________________________ (Corporation, partnership, or sole proprietor), doing business as ______________________________________________ (Store name) hereby certify:

(2) That said company is acquiring the pharmacy business of __________________________ ______________ (Name of Seller) doing business as ________________________________ with DEA Registration Number ____________________________________ on or about ______________________ (Date of Transfer) and that said company has applied (or will apply on _______________________ (Date) for a pharmacy permit from the Board of Pharmacy (or Licensing Agency) of the State of _____________________ to do business as _____________ _________________________ (Store name) at _____________________________ (Number and Street) ________________________ (City) ____________________ (State) ___________________ (Zip Code).

This statement is submitted in order to obtain a Drug Enforcement Administration registration number.

I understand that if a DEA registration number is issued, the pharmacy may acquire controlled substances but may not dispense them until a pharmacy permit or license is issued by the State board of pharmacy or licensing agency.

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

 ¹ 21 CFR, Section 1301.17(b)