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PHARMACY REGISTRATION

APPLICATION FOR REGISTRATION OF A PHARMACY

Section 1 - Type of Application (Tick appropriate box)

                                                                                           

Section 2 - Type of Pharmacy (Tick appropriate box)

                                                                                                                                                        

Section 3 - Pharmacy Information

Expected date of opening/ownership transfer:
Date of Inspection:
        

Section 4 - Pharmacy Ownership (Tick appropriate box)

The Pharmacy identified in section 3 is owned by the following - select only one, then enter name. An entry must be made. DO NOT enter "Same as Above".

Section 5 - List of Owner's Address

1. Enter the business address of the Corporation, LLC, Individual, Partnership, Association, etc. entered in Section 4. See note below.
2. Enter the business address of the Corporation, LLC, Individual, Partnership, Association, etc. entered in Section 4. See note below.

Section 6 - Ownership of Existing Registered Pharmacy

        

I hereby certify that I understand the Laws and Regulations and hereby undertake that the Pharmacy will be operated in accordance with such laws and regulations. I understand that this registration is valid for a period of one year and must be renewed thereafter.

Section 7 – Upload any relevent attachments

Upload certificate or identity attachments:

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