Form F-13 "Renewal or Discontinuation Application to Operate a Wholesale Drug or Medical Device Business" - New Jersey

What Is Form F-13?

This is a legal form that was released by the New Jersey Department of Health - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2019;
  • The latest edition provided by the New Jersey Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form F-13 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

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Download Form F-13 "Renewal or Discontinuation Application to Operate a Wholesale Drug or Medical Device Business" - New Jersey

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New Jersey Department of Health
FOR STATE USE ONLY
Consumer, Environmental and Occupational Health Service
Check No.:
PO Box 369, Trenton, NJ 08625-0369
Phone: 609-826-4935
Check Date:
www.nj.gov/health/foodanddrugsafety
RENEWAL OR DISCONTINUATION APPLICATION
Date Received:
TO OPERATE A WHOLESALE DRUG OR MEDICAL DEVICE BUSINESS
Amount:
PURSUANT TO N.J.S.A. 24:6B
January 31, 2020
FOR THE PERIOD ENDING:
Any person who engages or continues to engage in the manufacturing or wholesaling of drugs or medical devices without having
registered is guilty of a misdemeanor. ALL ITEMS MUST BE FULLY COMPLETED AND THE REQUESTED FEE RECEIVED BY
DECEMBER 31 IN ORDER TO BE RENEWED ON TIME.
Registered as:
Manufacturer
Wholesaler
Registration Number:
NEW FEE SCHEDULE
$200.00
If the business has less than 2 locations in state or out of state.
$500.00
If the business has 2 or more locations in state or out of state.
$50.00
For each location in the state if the gross total annual business
in drugs or medical devices does not exceed 3% of the gross
total annual volume.
CPA must complete and sign the
Certification section at the bottom of the form.
Make check payable to “Treasurer, State of NJ.” Payment must be
made with company check; no personal checks will be accepted.
Or, visit
nj.gov/health/foodanddrugsafety
and follow instructions for
online payment. A printed, signed renewal must be mailed.
_________________________
Federal ID Number:
LOCATIONS CURRENTLY CONDUCTING DRUG OR MEDICAL DEVICE BUSINESS
(ATTACH COPY OF CURRENT STATE LICENSE FOR EACH LOCATION.)
IF ADDING OR CHANGING ANY LOCATIONS, YOU MUST COMPLETE BELOW.
(MUST attach copy of license)
Company Name:
Street Address:
City, State, Zip Code:
Responsible Person:
Telephone Number:
Residential?
Yes
No
Activity Conducted:
Manufacturer
Warehouse
Repacker
Distributor
Broker Only
Relabeler
Reverse Distributor
Contract Manufacturer
Logistics Provider Company
(MUST attach copy of license)
Company Name:
Street Address:
City, State, Zip Code:
Responsible Person:
Telephone Number:
Residential?
Yes
No
Activity Conducted:
Manufacturer
Warehouse
Repacker
Distributor
Broker Only
Relabeler
Reverse Distributor
Contract Manufacturer
Logistics Provider Company
Changes Requested
Change in Trade Name
Change in Corporate Structure
Change in Mailing Address
Change in Ownership
NOTE: For changes that affect the legal entity or ownership, a new registration application must be completed. You are required to notify the New Jersey
Department of Health (NJDOH) of any intended/actual change in Trade Name, Corporate Structure, Mailing Address, or Change of Ownership. Change in
Ownership requires a new application to be completed.
DISCONTINUANCE OF OPERATIONS INFORMATION
(Include a detailed explanation that all inventory has been accounted for, reclaimed and/or disposed of properly, and the method used.)
Date Operations Discontinued
Reason for Discontinuation of Operations
Sold
Out of Business
Bankruptcy
Other:
If Sold, Name and Address of Purchaser
ALL ITEMS MUST BE FULLY COMPLETED OR THE RENEWAL APPLICATION
WILL NOT BE PROCESSED. RETAIN A COPY FOR YOUR RECORDS.
F-13
MAIL ORIGINAL COPY WITH YOUR FEE IN THE ENVELOPE PROVIDED.
JAN 19
Page 1 of 2 Pages.
New Jersey Department of Health
FOR STATE USE ONLY
Consumer, Environmental and Occupational Health Service
Check No.:
PO Box 369, Trenton, NJ 08625-0369
Phone: 609-826-4935
Check Date:
www.nj.gov/health/foodanddrugsafety
RENEWAL OR DISCONTINUATION APPLICATION
Date Received:
TO OPERATE A WHOLESALE DRUG OR MEDICAL DEVICE BUSINESS
Amount:
PURSUANT TO N.J.S.A. 24:6B
January 31, 2020
FOR THE PERIOD ENDING:
Any person who engages or continues to engage in the manufacturing or wholesaling of drugs or medical devices without having
registered is guilty of a misdemeanor. ALL ITEMS MUST BE FULLY COMPLETED AND THE REQUESTED FEE RECEIVED BY
DECEMBER 31 IN ORDER TO BE RENEWED ON TIME.
Registered as:
Manufacturer
Wholesaler
Registration Number:
NEW FEE SCHEDULE
$200.00
If the business has less than 2 locations in state or out of state.
$500.00
If the business has 2 or more locations in state or out of state.
$50.00
For each location in the state if the gross total annual business
in drugs or medical devices does not exceed 3% of the gross
total annual volume.
CPA must complete and sign the
Certification section at the bottom of the form.
Make check payable to “Treasurer, State of NJ.” Payment must be
made with company check; no personal checks will be accepted.
Or, visit
nj.gov/health/foodanddrugsafety
and follow instructions for
online payment. A printed, signed renewal must be mailed.
_________________________
Federal ID Number:
LOCATIONS CURRENTLY CONDUCTING DRUG OR MEDICAL DEVICE BUSINESS
(ATTACH COPY OF CURRENT STATE LICENSE FOR EACH LOCATION.)
IF ADDING OR CHANGING ANY LOCATIONS, YOU MUST COMPLETE BELOW.
(MUST attach copy of license)
Company Name:
Street Address:
City, State, Zip Code:
Responsible Person:
Telephone Number:
Residential?
Yes
No
Activity Conducted:
Manufacturer
Warehouse
Repacker
Distributor
Broker Only
Relabeler
Reverse Distributor
Contract Manufacturer
Logistics Provider Company
(MUST attach copy of license)
Company Name:
Street Address:
City, State, Zip Code:
Responsible Person:
Telephone Number:
Residential?
Yes
No
Activity Conducted:
Manufacturer
Warehouse
Repacker
Distributor
Broker Only
Relabeler
Reverse Distributor
Contract Manufacturer
Logistics Provider Company
Changes Requested
Change in Trade Name
Change in Corporate Structure
Change in Mailing Address
Change in Ownership
NOTE: For changes that affect the legal entity or ownership, a new registration application must be completed. You are required to notify the New Jersey
Department of Health (NJDOH) of any intended/actual change in Trade Name, Corporate Structure, Mailing Address, or Change of Ownership. Change in
Ownership requires a new application to be completed.
DISCONTINUANCE OF OPERATIONS INFORMATION
(Include a detailed explanation that all inventory has been accounted for, reclaimed and/or disposed of properly, and the method used.)
Date Operations Discontinued
Reason for Discontinuation of Operations
Sold
Out of Business
Bankruptcy
Other:
If Sold, Name and Address of Purchaser
ALL ITEMS MUST BE FULLY COMPLETED OR THE RENEWAL APPLICATION
WILL NOT BE PROCESSED. RETAIN A COPY FOR YOUR RECORDS.
F-13
MAIL ORIGINAL COPY WITH YOUR FEE IN THE ENVELOPE PROVIDED.
JAN 19
Page 1 of 2 Pages.
RENEWAL OR DISCONTINUATION APPLICATION
TO OPERATE A WHOLESALE DRUG OR MEDICAL DEVICE BUSINESS
(Continued)
ALL ITEMS MUST BE FULLY COMPLETED OR THE RENEWAL APPLICATION
WILL NOT BE PROCESSED. RETAIN A COPY FOR YOUR RECORDS.
MAIL ORIGINAL COPY WITH YOUR FEE IN THE ENVELOPE PROVIDED.
Full Legal Name of Authorized Representative for NJ Commerce (as defined in N.J.S.A. 24:6B-19)
Social Security Number
(First, Middle, Last):
Title
Email Address
Street Address
Telephone Number
City, State, Zip Code
Fax Number
ATTESTATIONS
1. Has any employee, officer, stockholder, board member associated with the company been indicted or convicted
of any federal, state, or local law relating to drug samples, drug manufacturing, wholesale or retail drug
distribution, or distribution of control substances? (If yes, please explain and attach the court decision and
adjudication.) ................................................................................................................................................................
Yes
No
2. Has the company furnished any false or fraudulent material in any applications made in connection with drug
manufacturing or distribution? (If yes, please explain.) ................................................................................................
Yes
No
3. Have any inspections of your facility resulted in deficient ratings? (If yes, please explain.) ...........................................
Yes
No
4. Has your company met all licensing requirements of your state? Please attach a copy of your most current
inspection. (If no, please explain.) ................................................................................................................................
Yes
No
5. To the best of your knowledge has the company been denied a license to manufacture and/or distribute
prescription drugs in your state, or any other state? (If yes, please explain.) ................................................................
Yes
No
(To be signed by individual Owner, Partner, Corporate President or Shareholder Principal, whichever is applicable.)
I hereby certify that the information given in this statement for Registration is true and complete to the best of my information and belief.
Full Legal Name (First, Middle, Last)
Title
Telephone Number
Signature
Date
COMPLETE THIS CERTIFICATION ONLY IF YOU ARE FILING FOR THE $50.00 FEE
CERTIFICATION BY CERTIFIED PUBLIC ACCOUNTANT (CPA)
I hereby certify that the gross total business in drugs or medical devices of Registrant named above does not exceed 3% of the
gross total annual volume of business of the registrant.
Signature
Date
Name of Certified Public Accountant (CPA)
License Number
Street Address
City, State, Zip Code
IMPORTANT: YOU MUST ATTACH A COPY OF THE CURRENT STATE LICENSE FOR EACH LOCATION, OR THE RENEWAL
APPLICATION WILL NOT BE PROCESSED. THIS RENEWAL APPLICATION MUST BE RECEIVED BY DECEMBER
31, IN ORDER FOR THE COMPANY REGISTRATION TO BE RENEWED ON TIME.
ALL ITEMS MUST BE FULLY COMPLETED OR THE RENEWAL APPLICATION
WILL NOT BE PROCESSED. RETAIN A COPY FOR YOUR RECORDS.
F-13
MAIL ORIGINAL COPY WITH YOUR FEE IN THE ENVELOPE PROVIDED.
JAN 19
Page 2 of 2 Pages.
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