Form DBPR-DDC-226 "Application for Certification as a Designated Representative" - Florida

What Is Form DBPR-DDC-226?

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 January 1, 2018;
  • 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-226 by clicking the link below or browse more documents and templates provided by the Florida Department of Business & Professional Regulation.

ADVERTISEMENT
ADVERTISEMENT

Download Form DBPR-DDC-226 "Application for Certification as a Designated Representative" - Florida

Download PDF

Fill PDF online

Rate (4.6 / 5) 16 votes
State of Florida
Department of Business and Professional Regulation
Division of Drugs, Devices, and Cosmetics
Application for Certification as a Designated Representative
Form No: DBPR-DDC-226
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
APPLICATION
APPLICATION REQUIREMENTS
Enclose nonrefundable fee of $150.00.
Make cashier’s check, corporate or business check, or money order
payable to the Florida Department of Business and Professional Regulation, or
Application for
DBPR.
Certified Designated
Representative
Sign and date the Affidavit section of the application.
Complete and execute under oath the Personal Information Statement.
Submit the completed application with enclosures to:
Department of Business and Professional Regulation
2601 Blair Stone Road
Tallahassee, FL 32399-1047
General Information
1.
Examination. To become certified an applicant must receive a passing score of at least 75 percent
on the Certified Designated Representative examination. The examination is very rigorous and tests
the candidate’s knowledge of state and federal laws and rules governing the distribution of
prescription drugs. An applicant must pass the examination within 18 months of being notified that
(s)he is eligible or the application will be denied.
2.
Experience. An applicant for examination as a Certified Designated Representative must
demonstrate that the applicant has at least 2 years of verifiable full-time:
a. Work experience in a pharmacy licensed in this state or another state, where the applicant's
responsibilities included, but were not limited to, recordkeeping for prescription drugs;
b. Managerial experience with an establishment licensed and authorized in this state or in another
state to wholesale distribute prescription drugs; OR
c. Managerial experience with the United States Armed Forces, where the applicant's
responsibilities included, but were not limited to, recordkeeping, warehousing, distributing, or
other logistics services pertaining to prescription drugs.
For the purpose of the work experience required to be certified as a designated representative:
1. Serving in a managerial capacity does not require actual supervisory responsibilities over
employees, but requires a level of responsibility consistent with a managerial employee, including but
not limited to decision-making authority, responsibility for developing and implementing policies and
procedures related to purchasing, sales, or inventory management for prescription drugs.
Page 1 of 23
State of Florida
Department of Business and Professional Regulation
Division of Drugs, Devices, and Cosmetics
Application for Certification as a Designated Representative
Form No: DBPR-DDC-226
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
APPLICATION
APPLICATION REQUIREMENTS
Enclose nonrefundable fee of $150.00.
Make cashier’s check, corporate or business check, or money order
payable to the Florida Department of Business and Professional Regulation, or
Application for
DBPR.
Certified Designated
Representative
Sign and date the Affidavit section of the application.
Complete and execute under oath the Personal Information Statement.
Submit the completed application with enclosures to:
Department of Business and Professional Regulation
2601 Blair Stone Road
Tallahassee, FL 32399-1047
General Information
1.
Examination. To become certified an applicant must receive a passing score of at least 75 percent
on the Certified Designated Representative examination. The examination is very rigorous and tests
the candidate’s knowledge of state and federal laws and rules governing the distribution of
prescription drugs. An applicant must pass the examination within 18 months of being notified that
(s)he is eligible or the application will be denied.
2.
Experience. An applicant for examination as a Certified Designated Representative must
demonstrate that the applicant has at least 2 years of verifiable full-time:
a. Work experience in a pharmacy licensed in this state or another state, where the applicant's
responsibilities included, but were not limited to, recordkeeping for prescription drugs;
b. Managerial experience with an establishment licensed and authorized in this state or in another
state to wholesale distribute prescription drugs; OR
c. Managerial experience with the United States Armed Forces, where the applicant's
responsibilities included, but were not limited to, recordkeeping, warehousing, distributing, or
other logistics services pertaining to prescription drugs.
For the purpose of the work experience required to be certified as a designated representative:
1. Serving in a managerial capacity does not require actual supervisory responsibilities over
employees, but requires a level of responsibility consistent with a managerial employee, including but
not limited to decision-making authority, responsibility for developing and implementing policies and
procedures related to purchasing, sales, or inventory management for prescription drugs.
Page 1 of 23
2. Responsibilities related to recordkeeping for prescription drugs by a person who worked in a
pharmacy may include such activities as, practicing pharmacy pursuant to a valid pharmacy license,
routinely purchasing or ordering prescription drugs where cognitive functions were involved and the
order is not the result of an automated reorder system, routinely receiving prescription drugs and
verifying the accuracy of the order, routinely taking a physical inventory of prescription drugs,
routinely assessing the pharmacy shelves for outdated prescription drugs, and routinely completing
an inventory for the transfer of adulterated prescription drugs for appropriate disposal.
3.
Please see sections 499.012(9) and (15), Florida Statutes and Rule 61N-1.015(9), Florida
Administrative Code, for more information regarding the Certified Designated Representative
licensing requirements.
4.
Fingerprints. The department is required to obtain a criminal record check of you prior to determining
your application is complete. The quickest method to obtain a criminal record check is to submit your
fingerprints electronically through a LiveScan vendor and pay the vendor directly. Information on
approved LiveScan vendors and submission of electronic fingerprinting is attached to this form. If
you choose to submit your fingerprints by using a fingerprint hard card, you may obtain a card from
the Division.
Note: If you have undergone a criminal record check as a condition of the issuance of an initial
permit or the initial renewal of a permit after January 1, 2004, then you do not need to submit a new
fingerprint card or electronic fingerprints.
5.
TYPE OR PRINT LEGIBLY an answer to every question. Use the last page of the form to provide
additional explanations to questions where the form does not have sufficient room for your response.
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. 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-226 - Application for Certification as a Designated Representative
Personal Information Statement
Incorporated by Rule: 61N-2.033, F.A.C.
Eff. Date: January 2018
Page 2 of 23
State of Florida
Department of Business and Professional Regulation
Division of Drugs, Devices, and Cosmetics
Application for Certification as a Designated Representative
Form No.: DBPR-DDC-226
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Division of Drugs, Devices and Cosmetics, 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 [3314/1010]
Section II – Applicant Information
APPLICANT INFORMATION
Applicant’s Name (Last, First, Middle, Former):
Social Security Number:
Date of Birth:
APPLICANT’S RESIDENCE ADDRESS
Street Address:
City:
State:
Zip Code (+4 optional):
Residence Telephone Number:
Work Telephone Number:
Fax Number:
Email Address:
APPLICANT’S MAILING ADDRESS
Street Address or PO Box:
City:
State:
Zip Code (+4 optional):
E-Mail Address:
Fax Number:
EMPLOYMENT INFORMATION
Establishment Name (If applicable):
Establishment Address:
City
State
Zip Code (+4 optional)
List Establishment Florida Permit Number (If applicable)
DBPR-DDC-226 - Application for Certification as a Designated Representative
Personal Information Statement
Incorporated by Rule: 61N-2.033, F.A.C.
Eff. Date: January 2018
Page 3 of 23
Section III – Work Experience
WORK EXPERIENCE
TO BE COMPLETED FOR INITIAL CERTIFICATION AS DESIGNATED REPRESENTATIVE.
List all qualifying experience earned in and out of state. The applicant must have 2 years of verifiable full-
time work experience.
Please check only one applicable experience type for this employment. Please fill out a separate
work experience section for each employer under which you gain applicable experience. If
additional work experience sections are required, you may copy the “Work Experience” section of
the application as needed to provide the 2 years of verifiable full-time employment.
 Work experience in a pharmacy licensed in this state or another state, where the person’s
responsibilities included, but were not limited to, recordkeeping for prescription drugs.
Permit No.:__________________
 Managerial experience with a prescription drug wholesale distributor licensed in Florida or in another
state and authorized to distribute prescription drugs.
Permit No.:__________________ and State of issuance:_______________________
 Managerial experience with the United States Armed Forces where the person’s responsibilities
included, but were not limited to, recordkeeping, warehousing, distributing, or other logistics services
pertaining to prescription drugs.
U.S. Military Branch:___________________________
Name of Employer:
Dates of Employment:
From: ___________ To: ____________
Total Years/Months of qualifying
experience: ____________________
Street Address:
Phone No.:
City:
State:
Zip Code (+4 optional):
Provide name, title, and work telephone number of person having direct knowledge of your experience.
Name:
Title:
Work Telephone Number:
Describe your duties that would qualify as work experience as outlined above.
DBPR-DDC-226 - Application for Certification as a Designated Representative
Personal Information Statement
Incorporated by Rule: 61N-2.033, F.A.C.
Eff. Date: January 2018
Page 4 of 23
WORK EXPERIENCE
TO BE COMPLETED FOR INITIAL CERTIFICATION AS DESIGNATED REPRESENTATIVE.
List all qualifying experience earned in and out of state. The applicant must have 2 years of verifiable full-
time work experience.
Please check only one applicable experience type for this employment. Please fill out a separate
work experience section for each employer under which you gain applicable experience. If
additional work experience sections are required, you may copy the “Work Experience” section of
the application as needed to provide the 2 years of verifiable full-time employment.
 Work experience in a pharmacy licensed in this state or another state, where the person’s
responsibilities included, but were not limited to, recordkeeping for prescription drugs.
Permit No.:______________
 Managerial experience with a prescription drug wholesale distributor licensed in Florida or in another
state and authorized to distribute prescription drugs.
Permit No.:___________________ State of issuance:_______________________
 Managerial experience with the United States Armed Forces where the person’s responsibilities
included, but were not limited to, recordkeeping, warehousing, distributing, or other logistics services
pertaining to prescription drugs.
U.S. Military Branch:___________________________
Name of Employer:
Dates of Employment:
From: ___________ To: ____________
Total Years/Months of qualifying
experience: ____________________
Street Address:
Phone No.:
City:
State:
Zip Code (+4 optional):
Provide name, title, and work telephone number of person having direct knowledge of your experience.
Name:
Title:
Work Telephone Number:
Describe your duties that would qualify as work experience as outlined above:
DBPR-DDC-226 - Application for Certification as a Designated Representative
Personal Information Statement
Incorporated by Rule: 61N-2.033, F.A.C.
Eff. Date: January 2018
Page 5 of 23