Pharmacist's Manual - APPENDIX A-N
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:
(1) That said company was issued a pharmacy permit No. ____________________ by the _____________________________ (Board of Pharmacy or Licensing Agency) of the State of ________________________ and a DEA Registration Number ____________________ for a pharmacy located at ___________________________________ (Number and Street), _________________________(City) __________________ (State) ________ (Zip Code); and
(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 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______.
1 21 C.F.R. § 1301.17(b)