Form DBPR-DDC-212 "Application for Restricted Prescription Drug Distributor - Institutional Research Permit" - Florida

What Is Form DBPR-DDC-212?

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 November 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-212 by clicking the link below or browse more documents and templates provided by the Florida Department of Business & Professional Regulation.

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State of Florida
Department of Business and Professional Regulation
Division of Drugs, Devices and Cosmetics
Application for Restricted Prescription Drug Distributor – Institutional Research Permit
Form No.: DBPR-DDC-212
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
APPLICATION
APPLICATION REQUIREMENTS
Enclose non-refundable biennial fee of $600.00.
Make cashier’s check, corporate or business check, or money order
Application for
payable to the Florida Department of Business and Professional Regulation or
Restricted
DBPR.
Prescription Drug
Distributor –
If the applicant answered “Yes” to any question in Section IV, enclose a
Institutional
detailed explanation along with any relevant documentation.
Research Permit
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-212 – Application for Restricted Prescription Drug Distributor – Institutional Research Permit
Eff. Date: November 2018
Page 1 of 10
State of Florida
Department of Business and Professional Regulation
Division of Drugs, Devices and Cosmetics
Application for Restricted Prescription Drug Distributor – Institutional Research Permit
Form No.: DBPR-DDC-212
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
APPLICATION
APPLICATION REQUIREMENTS
Enclose non-refundable biennial fee of $600.00.
Make cashier’s check, corporate or business check, or money order
Application for
payable to the Florida Department of Business and Professional Regulation or
Restricted
DBPR.
Prescription Drug
Distributor –
If the applicant answered “Yes” to any question in Section IV, enclose a
Institutional
detailed explanation along with any relevant documentation.
Research Permit
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-212 – Application for Restricted Prescription Drug Distributor – Institutional Research Permit
Eff. Date: November 2018
Page 1 of 10
State of Florida
Department of Business and Professional Regulation
Division of Drugs, Devices and Cosmetics
Application for Restricted Prescription Drug Distributor – Institutional Research Permit
Form No.: DBPR-DDC-212
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 [3355/1020]
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). [3355/1020]
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 Tax Identification Number:
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.
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
DBPR-DDC-212 – Application for Restricted Prescription Drug Distributor – Institutional Research Permit
Eff. Date: November 2018
Page 2 of 10
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:
Telephone Number:
Fax Number:
E-Mail Address:
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
The emergency contact is the person that the department will contact in the case of an emergency.
During an emergency, the department may contact this person at times outside of the regular business
hours listed below. The contact information provided should be sufficient for the department to reach and
communicate with the person listed.
Last/Surname:
First:
Middle:
Suffix:
Position/Title:
Street Address:
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. REMEMBER to circle “a.m.” or
“p.m.” for each time indicated below. The establishment must be open a minimum of 10 total hours 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:
DBPR-DDC-212 – Application for Restricted Prescription Drug Distributor – Institutional Research Permit
Eff. Date: November 2018
Page 3 of 10
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
Other:________________
Limited Liability Partnership and
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 the name and address of the applicant’s registered agent for service of process in Florida (except
Partnership – General or Sole Proprietorship) 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:
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:
DBPR-DDC-212 – Application for Restricted Prescription Drug Distributor – Institutional Research Permit
Eff. Date: November 2018
Page 4 of 10
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:
Street Address:
City:
State:
Zip Code:
DBPR-DDC-212 – Application for Restricted Prescription Drug Distributor – Institutional Research Permit
Eff. Date: November 2018
Page 5 of 10