Form DBPR-DDC-214 "Application for Permit as an Out-of-State Prescription Drug Wholesale Distributor" - Florida

What Is Form DBPR-DDC-214?

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 March 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-214 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 Permit as an Out-of-State Prescription Drug Wholesale Distributor
Form No.: DBPR-DDC-214
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your application to
ensure faster processing.
APPLICATION
APPLICATION REQUIREMENTS
Initial Permit. Nonrefundable biennial fee of $1,600.00.
Permit Renewal. Nonrefundable biennial fee of $1,600.00. To avoid a
$100 delinquent fee, your renewal must be postmarked 45 days prior to the
permit’s expiration date.
Make cashier’s check, corporate check, or money order payable to the
Application for
Florida Department of Business and Professional Regulation or DBPR.
Permit as an Out-of-
State Prescription
If you answer “Yes” to any question in Section IV, be sure to provide a
Drug Wholesale
detailed explanation along with any relevant documentation.
Distributor
Submit photocopy of your license/permit(s) issued by your resident state
that authorizes the distribution of prescription drugs from the applicant’s
address.
Sign and date the Affidavit section of the application.
Mail completed application 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)f,
499.012(8)(o), 499.63(2), 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-214-Application for Permit as an Out of State Prescription Drug Wholesale Distributor
Incorporated by rule: 61N-2.012 F.A.C.
Eff. Date: March 2017
Page 1 of 33
State of Florida
Department of Business and Professional Regulation
Division of Drugs, Devices, and Cosmetics
Application for Permit as an Out-of-State Prescription Drug Wholesale Distributor
Form No.: DBPR-DDC-214
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your application to
ensure faster processing.
APPLICATION
APPLICATION REQUIREMENTS
Initial Permit. Nonrefundable biennial fee of $1,600.00.
Permit Renewal. Nonrefundable biennial fee of $1,600.00. To avoid a
$100 delinquent fee, your renewal must be postmarked 45 days prior to the
permit’s expiration date.
Make cashier’s check, corporate check, or money order payable to the
Application for
Florida Department of Business and Professional Regulation or DBPR.
Permit as an Out-of-
State Prescription
If you answer “Yes” to any question in Section IV, be sure to provide a
Drug Wholesale
detailed explanation along with any relevant documentation.
Distributor
Submit photocopy of your license/permit(s) issued by your resident state
that authorizes the distribution of prescription drugs from the applicant’s
address.
Sign and date the Affidavit section of the application.
Mail completed application 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)f,
499.012(8)(o), 499.63(2), 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-214-Application for Permit as an Out of State Prescription Drug Wholesale Distributor
Incorporated by rule: 61N-2.012 F.A.C.
Eff. Date: March 2017
Page 1 of 33
State of Florida
Department of Business and Professional Regulation
Division of Drugs, Devices, and Cosmetics
Application for Permit as an Out-of-State Prescription Drug Wholesale Distributor
Form No.: DBPR-DDC-214
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
TYPE OF APPLICATION
Please indicate whether this is a new permit application or a permit renewal application?
New Application [3323/1021].
New Application – Change in Ownership or Control [3323/1021]. A new permit is required for a
change in ownership or controlling interest. Once a change of ownership occurs, you are prohibited
from distributing under the prior permit. You may not distribute prescription drugs in, into or from
Florida until a new permit has been issued. If this application is being filed due to a change in
ownership, please provide:
a. Prior Permit Number: __________ Name of Prior Owner: _______________________________
b. Legal documentation of the change in ownership or control, for example, a stock purchase
agreement or an executed contract for sale, etc.
If this application is being filed because there has been (or there will be in the immediate future) a
change in the ownership or controlling interest in the establishment, please provide documentation of
the change in ownership or control. If the change has not occurred, but is imminent, please check the
appropriate box and indicate the date that the change of ownership or control will take place.
The change in ownership or control became effective on ____/___/_____ and documentation (IS
) or
(IS NOT
) included.
The change in ownership or control is expected to become effective on ____/___/_____ and
documentation thereof will be provided to the division within 30 days of the effective date. I understand
that the application is incomplete until documentation of the change in ownership or control is received
by the division.
Renewal Application [3323/2020]. NOTE: To avoid the $100 delinquent fee, your renewal must be
postmarked 45 days prior to the permit’s expiration date.
Current Permit Number: ____________ Current Expiration Date:__________________
Initials ________ Date ___________
DBPR-DDC-214-Application for Permit as an Out of State Prescription
Drug Wholesale Distributor
Incorporated by rule: 61N-2.012 F.A.C.
Eff. Date: March 2017
Page 2 of 33
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).
Applicant’s TIN/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”, “D/B/A”, 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 MAILING ADDRESS
Street Address or P.O. Box:
City:
State:
Zip Code (+4 optional):
E-Mail Address:
Telephone Number:
Fax Number:
PHYSICAL ADDRESS OF ESTABLISHMENT TO BE PERMITTED
(only if different from mailing address) Check
if not applicable
Street Address:
City:
State:
Zip Code (+4 optional):
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:
DBPR-DDC-214-Application for Permit as an Out of State Prescription Drug Wholesale Distributor
Initials ________ Date ___________
Incorporated by rule: 61N-2.012 F.A.C.
Eff. Date: March 2017
Page 3 of 33
Address:
City:
State:
Zip Code (+4 optional):
E-Mail Address:
Telephone Number:
Fax Number:
EMERGENCY CONTACT 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 normal 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:
City:
State:
Zip Code (+4 optional):
E-Mail Address:
Telephone Number:
Fax Number:
BUSINESS HOURS
NORMAL BUSINESS HOURS
Normal business hours are those hours, Monday through Friday, between 8:00 a.m. and 5:00 p.m. Eastern
Time, during which the establishment and the establishment’s onsite management and or administrative
office, if either are present, conducts regular business activities.
List the establishment’s daily normal business hours in terms of Eastern Time. REMEMBER to circle “a.m.”
or “p.m.” for each time indicated below.
Mon
:
a.m./p.m. to
:
a.m./p.m.
Thu
:
a.m./p.m. to
:
a.m./p.m.
Tue
:
a.m./p.m. to
:
a.m./p.m.
Fri
:
a.m./p.m. to
:
a.m./p.m.
Wed
:
a.m./p.m. to
:
a.m./p.m.
Initials ________ Date ___________
DBPR-DDC-214-Application for Permit as an Out of State Prescription Drug Wholesale Distributor
Incorporated by rule: 61N-2.012 F.A.C.
Eff. Date: March 2017
Page 4 of 33
OPERATING HOURS
Operating hours are those hours, Sunday through Saturday, between 12:00 a.m. and 11:59 p.m. Eastern
Time, during which the establishment conducts regular business activities. (Including but not limited to
picking for orders and stocking inventory.)
The operating hours include the establishment’s normal
business hours and those hours outside of normal business hours where the establishment and the
establishment’s onsite management and or administrative office, if either is present, are not open to the
public or its customers.
List the establishment’s daily hours operating hours in terms of Eastern Time. REMEMBER to circle “a.m.”
or “p.m.” for each time indicated below.
Sun
:
a.m./p.m. to
:
a.m./p.m.
Thu
:
a.m./p.m. to
:
a.m./p.m.
Mon
:
a.m./p.m. to
:
a.m./p.m.
Fri
:
a.m./p.m. to
:
a.m./p.m.
Tue
:
a.m./p.m. to
:
a.m./p.m.
Sat
:
a.m./p.m. to
:
a.m./p.m.
Wed
:
a.m./p.m. to
:
a.m./p.m.
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 Liability
or Association
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:
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:
DBPR-DDC-214-Application for Permit as an Out of State Prescription Drug Wholesale Distributor
Incorporated by rule: 61N-2.012 F.A.C.
Initials ________ Date ___________
Eff. Date: March 2017
Page 5 of 33