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The University of the State of New York

THE STATE EDUCATION DEPARTMENT

Office of the Professions

New York State Board of Pharmacy

Lawrence H. Mokhiber

M/W

89 Washington Avenue

Executive Secretary

Albany, NY 12234-1000

INFORMATION

Phone: 518-474-3817 ext. 130

E-mail: pharmbd@mail.nysed.gov

FORM

REGISTRATION NUMBER: __________________________

PART I (Print in Black Ink)

(check one):

Manufacturer

Repacker of Drugs

Repacker of Medical Gases

Wholesaler

Name of owner/corporation under which registration has been issued or is sought:

Trade Name (if applicable):

M/W Address:

Street and Number

City

State

County

Zip Code

Complete ONE of the Following:

New Registration

Proposed date of opening:

mo .

day

yr.

Transfer of Ownership

Proposed date of transfer:

mo .

day

yr.

Name of previous registrant: _________________________________________________________________________

Registration number:

Change of location

Proposed Date of change:

mo .

day

yr.

Previous address: __________________________________________________________________________________

Renovation

Proposed date of renovation:

mo .

day

yr.

Update/Other _____________________________________________________________________________________

Has the applicant applied for or been issued registration at any other location in this state by this department?

Yes

If yes, please list the address and registration number. Use additional paper if necessary.

_______________________________________________________________________________________ ______________________________

Location and Address

Registration Number

Does this applicant have a New York State registered pharmacy?

Yes

6 List Supervisor of this establishment

_______________________________________________________________________________________________________________________

Form MW 111, Page 1 of 4, February 2006

A. Nature of registration:
Manufacturer/wholesaler	Yes	No	Wholesaler only	Yes	No
Repacker/wholesaler	Yes	No	Medical gas repackager	Yes	No

B.Daily schedule of hours the establishment will be opened. (list days of week and hours opened.)

___________________________________________________________________________________________________________________

C.List percent of business done with the following (must equal 100%):

Domestic __________ %	Foreign __________ %
Check ALL items distributed at this location.
Prescription required drugs (human)		Medical Devices	Prescription required drugs (animal)
Hypodermic syringes and needles		Controlled substances	Compressed medical gases/liquid
Over the counter drugs		Cosmetics
Other ___________________________________________________________________________________________________________
Building/Space Requirements
Has the following been adequately provided for? (check yes or no)
Adequate lighting			Yes	No
Appropriate sanitation			Yes	No
Adequate space			Yes	No
Necessary equipment			Yes	No
Appropriate security			Yes	No
Secure quarantine area			Yes	No
Orderly stock control			Yes	No
Free from insects, rodents, birds or vermin			Yes	No
Drug areas secure from unauthorized entry			Yes	No
Outside access well controlled and kept to a minimum			Yes	No
Outside perimeter well lighted			Yes	No
Alarm system for after hours			Yes	No
Security system against theft and diversion			Yes	No
Computer and electronic system security against theft and diversion			Yes	No
Temperature control			Yes	No
Humidity control			Yes	No
Written policies and procedures for distribution/recalls etc.			Yes	No
Hot and cold running water			Yes	No
Recording equipment used for temperature/humidity (check each):
Manual			Yes	No
Electromagnetic			Yes	No
Electronic			Yes	No
Neighborhood (check type):
Commercial			Yes	No
Residential			Yes	No
Both			Yes	No
Pharmacy Guide to Practice, Reference books, etc.			Yes	No

FOR MANUFACTURERS AND REPACKERS ONLY

Supervision
Will all manufacturing and/or repacking be done under the personal supervision of a licensed pharmacist?	Yes	No

Supervisor’s who are not pharmacists shall meet the requirements as outlined in Section 63.6 (c)(1) of the regulations for registration and operation and of the establishments.

Do you have storage or manufacturing facilities for drug products at an address other than that indicated?	Yes	No
If your answer is “Yes,” indicated locations and explain:

_______________________________________________________________________________________________________________________

Form MW 111, Page 2 of 4, February 2006

2 Indicate Scale ________________________ sq. ft.

1 Total registered area ___________________ sq. ft.

PART II

•Draw to scale the proposed establishment, indicating all dimensions. Show all doors and walls.

•Indicate areas for storage of drugs (drug bays).

•In red pen, indicate R for refrigerator.

•In red pen indicate S for sink that is located in the compounding and dispensing area.

•Outline the registered area in yellow.

•Indicate the premises adjacent to the buildings, offices and public thoroughfares.

•Name the adjacent businesses.

•DO NOT SEND A BLUEPRINT, IT WILL BE DISCARDED.

Form MW111, Page 3 of 4, February 2006

PART III

Contact person to clarify information provided on this application:

Name: _______________________________________________________________________________________________________

Phone: _______________________________________________________________________________________________________

Fax: _________________________________________________________________________________________________________

Email address: ________________________________________________________________________________________________

PART IV: ATTESTATION

I affirm that all information submitted to the Board of Pharmacy is true. I am familiar with the Pharmacy Guide to Practice and the laws which govern the distribution of drugs and/or devices in New York State and with the Title 21 Code of Federal Regulations Part 205. I further understand that manufacturers, repackers and wholesalers may only sell drugs and/or devices to those purchasers authorized by law to receive them, and that records of the receipt and disposition of all drugs and/or devices shall be maintained for a period of five years and shall be available to the Department or any other authorized State or Federal agency for a period of not less than five years.

____________________________________________________________________________	______________________________
Signature of applicant (Individual owner, partner, corporate officer, or *other authorized person)	Date
____________________________________________________________________________	______________________________
Print Name	Date
*Power of attorney must be submitted for “other authorized person”

PART V: INSPECTION

Investigator’s Comments:

_____________________________________________________________________________________________________________

____________________________________________________________________________	______________________________
Signature – Investigator Office of Professional Discipline	Date
____________________________________________________________________________
Print name

Form MW111, Page 4 of 4, February 2006

Question	Answer
Form Name	Form Mw111
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	pharm mw111 how to fill out mw111 form

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