Form DBPR-DDC-234 "Application for a Restricted Prescription Drug Distributor - Blood Establishment" - Florida

What Is Form DBPR-DDC-234?

This is a legal form that was released by the Florida Department of Business & Professional Regulation - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2017;
  • The latest edition provided by the Florida Department of Business & Professional Regulation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DBPR-DDC-234 by clicking the link below or browse more documents and templates provided by the Florida Department of Business & Professional Regulation.

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Download Form DBPR-DDC-234 "Application for a Restricted Prescription Drug Distributor - Blood Establishment" - Florida

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State of Florida
Department of Business and Professional Regulation
Drugs, Devices, and Cosmetics Program
Application for a Restricted Prescription Drug Distributor – Blood Establishment
Form No.: DBPR-DDC-234
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
APPLICATION
APPLICATION REQUIREMENTS
Enclose the nonrefundable biennial fee of $600.00.
Application for
 Make cashier’s check, corporate check, or money order payable to the
Permit as a
Florida Department of Business and Professional Regulation or DBPR.
Restricted
Prescription Drug
If the applicant answered “Yes” to any question in Section IV, enclose a
Distributor – Blood
detailed explanation along with any relevant documentation.
Establishment
Sign and date the Affidavit section of the application.
Submit the completed application with enclosures to:
Department of Business and Professional Regulation
2601 Blair Stone Road
Tallahassee, FL 32399-1047
PLEASE NOTE:
Telephone, email, and fax contact information is used to quickly resolve questions with
applications. If such information is not provided, questions regarding applications will be mailed
to the application contact’s mailing address and may take longer to resolve.
The disclosure of Social Security numbers is mandatory on all professional and occupational
license applications, is solicited by the authority granted by 42 U.S.C. §§ 653 and 654, and will be
used by the Department of Business and Professional Regulation pursuant to §§ 409.2577,
409.2598, 499.012(4)(a)5.f, 499.012(8)(o), and 559.79(3), Florida Statutes, for the efficient screening
of applicant and licensees by a Title IV-D child support agency to assure compliance with child
support obligations. It is also required by §559.79(1), Florida Statutes, for determining eligibility
for licensure and mandated by the authority granted by 42 U.S.C. § 405(c)(2)(C)(i), to be used by
the Department of Business and Professional Regulation to identify licensees for tax
administration purposes.
DBPR-DDC-234 - Application for Licensure as a Restricted Prescription Drug Distributor – Blood Establishment
Eff. Date: December 2017
Incorporated by Rule: 61N-2.018, F.A.C.
Page 1 of 10
State of Florida
Department of Business and Professional Regulation
Drugs, Devices, and Cosmetics Program
Application for a Restricted Prescription Drug Distributor – Blood Establishment
Form No.: DBPR-DDC-234
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
APPLICATION
APPLICATION REQUIREMENTS
Enclose the nonrefundable biennial fee of $600.00.
Application for
 Make cashier’s check, corporate check, or money order payable to the
Permit as a
Florida Department of Business and Professional Regulation or DBPR.
Restricted
Prescription Drug
If the applicant answered “Yes” to any question in Section IV, enclose a
Distributor – Blood
detailed explanation along with any relevant documentation.
Establishment
Sign and date the Affidavit section of the application.
Submit the completed application with enclosures to:
Department of Business and Professional Regulation
2601 Blair Stone Road
Tallahassee, FL 32399-1047
PLEASE NOTE:
Telephone, email, and fax contact information is used to quickly resolve questions with
applications. If such information is not provided, questions regarding applications will be mailed
to the application contact’s mailing address and may take longer to resolve.
The disclosure of Social Security numbers is mandatory on all professional and occupational
license applications, is solicited by the authority granted by 42 U.S.C. §§ 653 and 654, and will be
used by the Department of Business and Professional Regulation pursuant to §§ 409.2577,
409.2598, 499.012(4)(a)5.f, 499.012(8)(o), and 559.79(3), Florida Statutes, for the efficient screening
of applicant and licensees by a Title IV-D child support agency to assure compliance with child
support obligations. It is also required by §559.79(1), Florida Statutes, for determining eligibility
for licensure and mandated by the authority granted by 42 U.S.C. § 405(c)(2)(C)(i), to be used by
the Department of Business and Professional Regulation to identify licensees for tax
administration purposes.
DBPR-DDC-234 - Application for Licensure as a Restricted Prescription Drug Distributor – Blood Establishment
Eff. Date: December 2017
Incorporated by Rule: 61N-2.018, F.A.C.
Page 1 of 10
State of Florida
Department of Business and Professional Regulation
Drugs, Devices, and Cosmetics Program
Application for Restricted Prescription Drug Distributor – Blood Establishment
Form No.: DBPR-DDC-234
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Drugs, Devices and Cosmetics Program, at
850.717.1800. For additional information see the Instructions at the beginning of this application.
Section I- Application Type
CHECK ONE OF THE APPLICATION TYPES
New Application [3357/1020]
New Application due to Change in Ownership. If checked, provide legal documentation for the
change of ownership (i.e. Bill of Sale, stock transfer, merger). [3357/1020]
Current Permit Number ___________________________
Section II – Applicant Information
APPLICANT INFORMATION
TAXPAYER IDENTIFICATION NUMBER OR FEDERAL EMPLOYER IDENTIFICATION NUMBER
This is a unique nine-digit number assigned by the Internal Revenue Service (IRS) to business entities
operating in the United States for the purposes of identification. When the number is used for
identification rather than employment tax reporting, it is usually referred to as a Taxpayer Identification
Number (TIN), and when used for the purposes of reporting employment taxes, it is usually referred to as
the Federal Employer Identification Number (FEIN).
Federal Employer Identification Number (FEIN):
FULL LEGAL NAME
The “full legal name” is the complete name of the business entity that will be operating the establishment.
This is generally the name that is on the documents that establish the existence or formation of the
business entity. For example, a corporation’s full legal name would normally be the name that is found in
the corporation’s articles of incorporation.
Applicant’s Full Legal Name:
FICTITIOUS, TRADE OR BUSINESS NAME
If the applicant intends to operate the permitted establishment under a name that is different from the
Applicant’s Full Legal Name listed above – e.g. fictitious, trade, or business name (also commonly
referred to as a “dba”, or “doing business as” name – this name must be registered with the Florida
Department of State, Division of Corporations. This is the name that will appear on the permit issued to
the applicant by the department and must be the name that the applicant uses on operational documents
for permitted activities.
DBPR-DDC-234 - Application for Licensure as a Restricted Prescription Drug Distributor – Blood Establishment
Eff. Date: December 2017
Incorporated by Rule: 61N-2.018, F.A.C.
Page 2 of 10
The applicant WILL NOT operate the permitted establishment under a name that is different from the
Applicant’s Full Legal Name listed above.
The applicant WILL operate the permitted establishment under the following fictitious, trade, or
business name: ___________________________________________________________________
The fictitious, trade, or business name listed directly above, is registered with the Florida Department
of State, Division of Corporations and the applicant has been issued the following registration
number: ______________________________.
APPLICANT’S MAILING ADDRESS
Street Address or P.O. Box:
City:
State:
Zip Code (+4 optional):
PHYSICAL ADDRESS OF ESTABLISHMENT TO BE PERMITTED
Street Address:
City:
State:
Zip Code (+4 optional):
County (if Florida address):
Country:
E-Mail Address:
Telephone Number:
Fax Number:
APPLICATION CONTACT
The application contact is the person that the department will contact if there are questions regarding the
responses provided on, or the documentation submitted with, the application. The application contact is
also the person that will receive all official communication from the department regarding the application.
Last/Surname:
First:
Middle:
Suffix:
Address:
City:
State:
Zip Code (+4 optional):
Telephone Number:
Fax Number:
E-Mail Address:
EMERGENCY CONTACT - RESIDENCE INFORMATION
The emergency contact is the person that the department will contact in the case of an emergency.
During an emergency, the department will contact this person at times outside of the regular business
hours listed below. The contact information provided should be sufficient for the department to actually
reach and communicate with the person listed in the event of an emergency.
Last/Surname:
First:
Middle:
Suffix:
Position/Title:
Street Address:
DBPR-DDC-234 - Application for Licensure as a Restricted Prescription Drug Distributor – Blood Establishment
Eff. Date: December 2017
Incorporated by Rule: 61N-2.018, F.A.C.
Page 3 of 10
City:
State:
Zip Code (+4 optional):
Telephone Number:
E-Mail Address:
OPERATING HOURS
List the establishment’s daily hours of operation in terms of Eastern Time. – minimum 10 total per week
(M-F) between 8:00 a.m. and 5:00 p.m., and at least 2 consecutive hours on at least 1 day. REMEMBER
to circle “a.m.” or “p.m.” for each time indicated below.
Mon
:
am/pm to
:
am/pm
Fri
:
am/pm to
:
am/pm
Tue
:
am/pm to
:
am/pm
Sat
:
am/pm to
:
am/pm
Wed
:
am/pm to
:
am/pm
Sun
:
am/pm to
:
am/pm
Thu
:
am/pm to
:
am/pm
Section III – Ownership Information
TYPE OF OWNERSHIP
Publicly Held Corporation
Closely Held Corporation
Limited Liability Company
Charitable Organization—501(c)(3)
Sole Proprietorship
Government
Partnership – General
Professional Corporation
Professional Limited
or Association
Liability Company
Partnership – Other, Including
Limited Liability Partnership and
Other:__________________
Limited Partnership
List the state of incorporation or state of organization (except Partnership – General or Sole
Proprietorship). Business entities organized under non-U.S. laws list the country of organization.
N/A (Partnership – General or Sole Proprietorship)
State or Country:
List name and address of the applicant’s registered agent for service of process in Florida (except Sole
Proprietorship or Partnership – General) and provide documentation, such as a print out from the Florida
Department of State, Division of Corporations’ webpage, that the applicant’s registered agent is
registered with the Florida Department of State, Division of Corporations.
N/A (Partnership – General or Sole Proprietorship)
Name:
Address:
City:
State:
Zip Code (+4 optional)
List the name, position/title, social security number, date of birth and address of each owner, partner,
member, manager, officer, director, chief executive, or other person who directly or indirectly controls the
operation of the business entity, as applicable. For example, corporations would list officers and
directors, limited liability companies would list members and managers, etc.
1.
Name & Title:
Social Security #:
Date of Birth:
% of Ownership:
Street Address:
City:
State:
Zip Code:
DBPR-DDC-234 - Application for Licensure as a Restricted Prescription Drug Distributor – Blood Establishment
Eff. Date: December 2017
Incorporated by Rule: 61N-2.018, F.A.C.
Page 4 of 10
2.
Name & Title:
Social Security #:
Date of Birth:
% of Ownership:
Street Address:
City:
State:
Zip Code:
3.
Name & Title:
Social Security #:
Date of Birth:
% of Ownership:
Street Address:
City:
State:
Zip Code:
4.
Name & Title:
Social Security #:
Date of Birth:
% of Ownership:
Street Address:
City:
State:
Zip Code:
5.
Name & Title:
Social Security #:
Date of Birth:
% of Ownership:
Street Address:
City:
State:
Zip Code:
6.
Name & Title:
Social Security #:
Date of Birth:
% of Ownership:
Street Address:
City:
State:
Zip Code:
7.
Name & Title:
Social Security #:
Date of Birth:
% of Ownership:
Street Address:
City:
State:
Zip Code:
8.
Name & Title:
Social Security #:
Date of Birth:
% of Ownership:
Street Address:
City:
State:
Zip Code:
List the name, social security number, date of birth and address of each person who owns 10 percent or
more of the outstanding stock or equity interest in the business entity.
1.
Name:
Social Security #:
Date of Birth:
% of Ownership:
Street Address:
City:
State:
Zip Code:
2.
Name:
Social Security #:
Date of Birth:
% of Ownership:
DBPR-DDC-234 - Application for Licensure as a Restricted Prescription Drug Distributor – Blood Establishment
Eff. Date: December 2017
Incorporated by Rule: 61N-2.018, F.A.C.
Page 5 of 10