Vermont Pharmacy License Verification Details

As a Vermont non-resident, you may be wondering how to get your prescriptions filled while living in the state. The good news is that there is a pharmacy form designed specifically for non-residents. This article will provide an overview of the Vermont Non Resident Pharmacy Form, including what it is and who can use it.

You'll find more info relating to the vermont non resident pharmacy form by checking out the table we compiled.

QuestionAnswer
Form NameVermont Non Resident Pharmacy Form
Form Length8 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min
Other namesvermont board of pharmacy forms, vermont non pharmacy, vermont pharmacy license verification, application vermont drug

Form Preview Example

Vermont Secretary of State

Office of Professional Regulation

VERMONT BOARD OF PHARMACY

National Life Building, North, FL 2

Montpelier, VT 05620-3402

Ph: (802) 828-2373 or 828-1505

Fax: (802) 828-2465

E-Mail: “kkemp@sec.state.vt.us”

Web Site: www.vtprofessionals.org

INSTRUCTION SHEET FOR NON-RESIDENT (OUT-OF-STATE) DRUG OUTLET (PHARMACY)

You may contact Kristy Kemp, Administrative Assistant, at (802) 828-2373 or via E-mail: kkemp@sec.state.vt.us if you have questions or if you need additional information.

Once your application is complete, it will be sent to the Board for review. The Board usually meets on the fourth Wednesday of each month. See the Board’s Web site for specific meeting dates, agendas, minutes, etc.

This application applies to out-of-state (Non-Resident) drug outlets or pharmacies. See Part 16 of the Board’s Rules. http://vtprofessionals.org/opr1/pharmacists/rules.asp

“Non-resident pharmacy” means a drug outlet located outside of this state which dispenses prescription drugs or devices to Vermont residents or residents of other states and which mails, ships, or delivers such prescription drugs or devices into this state or which provides any type of pharmacy services.

All signatures required on the application must be those of an Owner, a Partner, or Corporate Officer.

Non-Resident Pharmacies / Drug Outlets must submit the following:

1.Completed application

2.Application fee of $300.00. Please make your check payable to Vermont Secretary of State. Application fees are non-refundable.

3.Verification of licensure standing directly from the licensing authority in the state where the pharmacy is located that will be shipping drugs to Vermont. No form is provided. Contact your state’s Board of Pharmacy or applicable licensing authority and request that a verification of good standing be sent to Vermont. Note: Online verification is acceptable provided the state in which the facility is located reports whether disciplinary action(s) has been taken against the applicant.

4.List(s) of the names of all owners. Indicate whether sole proprietor, partnership, corporation, limited liability company, etc. Note: Changes in ownership require submittal of a new application.

Provide a flow chart showing ownership. If an actual flow chart is not available, a description of the ownership or hierarchy of the organization is acceptable. (See Board Rule 16.2 (c))

(1)If a person: the name, business address, and date of birth;

(2)If a partnership: the name, business address, and date of birth of each partner, and the name of the partnership;

(3)If a sole proprietorship: the full name, business address, social security number, and date of birth of the sole proprietor and the name of the business entity; and

(4)If a corporation: the federal identification number of the corporation, the name, business address,

date of birth, and title of each corporate officer and director, the corporate names, the name of the state of incorporation, and the name of the parent company, if any; the name, business address of each shareholder owning five percent or more of the voting stock of the corporation, including over-the- counter stock, unless the stock is traded on a major stock exchange and not over-the-counter;

5.Affirmation Forms completed by the sole proprietor, all members, all partners, or corporate officers and directors, and the pharmacist-manager, that they have not been convicted of, and are not under indictment for, any felony or misdemeanor arising from the violation of any drug or pharmacy related law. Questions must be answered and your signature must be notarized. (Rule 16.2)

6.Required Statement(s). The Pharmacist Manager may sign the form provided with this application regarding the required statements or may make the statements on pharmacy letterhead. A copy of the prescription label with toll free number may be applied to this statement or attached separately.

(See Board Rule 16.2 (e) (f) and (g)).

7.A copy of the most recent inspection report from the state in which the pharmacy is located; and

Effective July 1, 2010: For internet non-resident pharmacies, a copy of an inspection report not more than three years old by either:

(1)the state in which the pharmacy is located; or

(2)Verified Internet Pharmacy Practice Sites (VIPPS) certification.

Where the Pharmacy Board in the other state has not inspected the pharmacy in the past three years through no fault of the pharmacy, the pharmacy may advise this Board of the inspection delay and this Board may grant the pharmacy an extension of up to one year to allow the pharmacy to comply with this rule.

8.Disciplinary Actions or Denials: Answers to these questions pertain to the applicant, its parent, subsidiaries, or another person or organization with a controlling interest in the drug outlet. If the answer is “yes” on the application form, provide certified copies of the charges, if filed, and of the Final Disposition Order. In addition, a signed and sworn statement from the CEO, COO, president or equivalent management level corporate officer showing how the company has responded to the prior violation such that the Vermont Board of Pharmacy can be assured that a repeat or similar violation will not occur in Vermont. Please also ask the state in which the action was taken to provide to the Board verification of current licensure standing. An Investigative Team will review this information to determine whether further investigation or action is needed before a final decision is made regarding your application.

If your Internet Pharmacy is certified by the National Association of Boards of Pharmacy’s Verified Internet Pharmacy Practice Sites (VIPPS) program, please provide a copy of your certification. For more information contact the NABP via www.nabp.net.

NOTE: All licensees renew on a fixed 24 month schedule: July 31 (odd numbered years). Applicants issued an initial license more than 90 days prior to the renewal date will be required to renew and pay the renewal fee. Initial licenses issued within 90 days of the renewal date will not be required to renew or pay the renewal fee.

The Statutes and Rules are available via the Board’s Web site at:

http://vtprofessionals.org/opr1/pharmacists/rules.asp

www.vtprofessionals.org

Vermont Secretary of State

Kristy Kemp

Office of Professional Regulation

Administrative Assistant

National Life Building, North FL 2

(802) 828-2373

Montpelier VT 05620-3402

kkemp@sec.state.vt.us

(802) 828-1505

www.vtprofessionals.org

Board of Pharmacy

Application for Licensure as a Non-Resident Pharmacy (Drug Outlet)

Name of Pharmacy

 

 

 

 

 

 

 

 

 

 

 

Mailing

 

 

 

 

City, State,

 

 

 

Address,

 

 

 

 

Zip

 

 

 

Street

 

 

 

 

 

 

 

 

 

Phone

 

 

Fax

 

 

Email

 

 

 

 

 

 

 

 

 

 

 

Federal Identification Number

 

 

Social Security No. (sole proprietor)

_____/___________________

 

 

 

_____/_____/____________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LEGAL ORGANIZATION:

 

 

Corporation

 

Individual

 

Partnership

 

Limited Liability Company

 

 

____Foreign Corporation

_____If Other, Indicate:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Owner

 

 

 

 

 

 

 

 

 

 

 

(entity or Individual)

 

 

 

 

 

 

 

 

 

 

 

List the name, date of birth and address of the sole proprietor, partners, members, etc.

Name of individual owner(s)

Date of Birth

Mailing Address

If corporate owner, provide names and addresses of officers and shareholders owning 5% or more. (Attach separate sheet if necessary). If no individual shareholder owns 5% or more, please state that fact below.

Shareholder’s Name

Date of Birth

Mailing Address

Name(s) and license number(s) of all pharmacists employed by the pharmacy, including employer if employer is a pharmacist.

Pharmacist Manager’s Name

License Number

Hours Pharmacy

open per week

Hours worked

per week

Name of other Pharmacists employed

here

License Number

Hours Pharmacy

open per week

Hours worked

per week

Toll Free Number:

Indicate hours that the pharmacy is open for business.

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Drug Enforcement Administration:

Is the applicant registered under the Controlled Substances Act? If Yes, provide a copy of your DEA Number Issued.

Yes

No

Vermont Mandatory “Good Standing” Declarations

CHILD SUPPORT:

Child Support Orders, 15 V.S.A. § 795

As of the date of this application: this business, and/or the person signing this form, (check one)

___Is not subject to a child support order; OR

___Is subject to a child support order and am in good standing* or in full compliance with a plan to pay

___Is not in good standing* or in full compliance with a plan to pay.*

TAXES:

Tax Compliance, 32 V.S.A. § 3113(b)

As of the date of this application: this business, and/or the person signing this form, (check one)

___ Has never lived or worked in Vermont and do not owe Vermont taxes; OR

___ Has no taxes due and payable and all required returns have been filed; OR

___ Has the liability for any taxes due and payable on appeal; OR

___ Is not in compliance with a payment plan approved by the Vermont Department of Taxes; OR

___ Is not in good standing* with the Vermont Department of Taxes or in full compliance with a plan to pay.

UNEMPLOYMENT COMPENSATION:

Unemployment Compensation, 21 V.S.A. §1378(b)

As of the date of this application: this business, and/or the person signing this form, states that: (check one)

___This does not apply because this business or I have never been an employer in Vermont; OR

___ No contributions or payments in lieu of contributions are due and payable; or the liability for any contributions or payments in lieu of contributions due and payable is on appeal; or the employing unit is in compliance with a payment plan approved by the commissioner; OR

___ this business or I am not in good standing* or in full compliance with a plan to pay.

DISTRICT COURT FINES / JUDICIAL BUREAU:

Unpaid Judgments, 4 V.S.A. § 1110(c)

As of the date of this application: this business, and/or the person signing this form: (check one)

_____Does not have any unpaid judgements

_____Is in good standing* with respect to any unpaid judgment issued by the judicial bureau or district

court for fines or penalties for a violation or criminal offense.”

_____Is not in good standing.*

*“Good standing” is defined in the statutes cited above. For more information, refer to the relevant statute specific to the particular question or consult the “information for applicants” on the OPR web page. (www.vtprofessionals.org)

Please note, answers to the questions apply to the applicant, its owner or parent, subsidiaries or any another person or entity with a controlling interest in this organization.

Vermont Mandatory Credential and Fitness Questions

Please circle Yes or No for each of these questions. If “Yes,” follow the provided instructions.

Has Vermont or any other state, federal authority, or other jurisdiction (US or elsewhere) denied an application for a license, certificate, or registration by this applicant to conduct business or perform professional services?

If “Yes,” attach a copy of the order or official notification of the action(s).

Yes

No

Has Vermont or any other state, federal authority or other jurisdiction (US or elsewhere) restricted, suspended, revoked, or taken any other disciplinary action against a license, certificate, or registration held by this applicant to conduct business or perform professional services?

If “Yes,” provide a copy of the order or official notification of the action.

Yes

No

Has the entity for which this application is submitted ever surrendered a license, certificate or registration to a licensing authority?

If “Yes,” provide a detailed written explanation.

Yes

No

Is the entity for which this application is submitted currently under investigation by a licensing authority?

If “Yes,” provide a detailed written explanation and a copy of any available information from the licensing authority.

Yes

No

Has the entity for which this application is submitted been convicted of a crime?

If “yes,” provide a detailed written explanation and attach the official court documents.

Yes

No

Does the entity for which this application is submitted have any criminal charges pending against it in any jurisdiction (US or elsewhere)?

If ”yes,” provide a detailed written explanation and attach a copy of the charging documents.

Yes

No

Note: Vermont law requires that you report to the Office of Professional Regulation a felony conviction or any conviction of a crime related to the practice of your profession, within 30 days. 3 V.S.A. § 129a (a)(11).

Statement of Applicant

I certify, under the pains and penalties of perjury, that all information I have provided in this application is true and accurate. I understand that furnishing false information may constitute unprofessional conduct and result in the denial of this application for licensure/certification/registration. The maximum penalty for perjury is fifteen years in prison and/or a $10,000 fine. (13 V.S.A. §2901)

I further certify that I have read and understand the laws and rules of the profession (www.vtprofessionals.org).

Signature of Applicant

Date

Print Name and Title of proprietor, partner, member or corporate officer:

Revised 12/09

Vermont Secretary of State, Office of Professional Regulation

VERMONT BOARD OF PHARMACY

National Life Building, North, FL 2, Montpelier, VT 05620-3402

www.vtprofessionals.org – (802) 828-2373

AFFIRMATION

Name of Pharmacy

(Applicant)

Your Name

Your Address

City, State, Zip

Date of Birth

 

Email Address

 

 

 

 

 

 

 

 

 

Check Applicable position or title:

 

 

 

 

____ Sole Proprietor

____ Partner

____ Corporate Officer

 

 

 

 

 

____ Director

____ Pharmacist-Manager

____ Other

 

 

 

 

 

 

 

The Board’s Rules require an Affirmation by the sole proprietor, all partners, members, or corporate officers and directors, and the pharmacist-manager, that they have not been convicted of, and are not under indictment for, any felony or misdemeanor arising from the violation of any drug or pharmacy related law.

Answer the questions below. If “Yes,” provide documentation.

Have you been convicted of, or under indictment for, any felony or misdemeanor arising from the

 

 

violation of any drug or pharmacy related law?

Yes

No

If “Yes,” attach court documents.

 

 

 

 

 

Has Vermont, any other state, territory, or other jurisdiction restricted, suspended, revoked, or

 

 

taken any other disciplinary action against a license, certificate, or registration that you hold or held

Yes

No

in any profession or occupation?

 

 

If “Yes,” provide a certified copy of the action.

 

 

 

 

 

Has Vermont, any other state, territory, or other jurisdiction denied your application for a license,

 

 

certificate, or registration in any profession or occupation?

Yes

No

If “Yes,” provide a certified copy of the order or official notification of the Board action.

 

 

CERTIFICATION OF APPLICANT

I certify, under the pains and penalties of perjury, that all information I have provided in this application is true and accurate. I understand that furnishing false information may constitute unprofessional conduct and result in the denial of my application for licensure/certification/registration. (The maximum penalty for perjury is Fifteen years in prison and/or a $10,000 fine.) (13 V.S.A. §2901)

Signature: ___________________________________________

Date: ____________________

STATE OF _________________________________ COUNTY OF

_

}ss.

Subscribed and sworn to before me this ________ day of ____________________, 20_________

(year)

____________________________________________ Commission Expires: ___________________

Notary Public

Vermont Secretary of State

Office of Professional Regulation

VERMONT BOARD OF PHARMACY

National Life Building, North, FL 2

Montpelier, VT 05620-3402

Ph: (802) 828-2373 Fax: (802) 828-2465

E-Mail: “kkemp@sec.state.vt.us”

STATEMENT(S) OF PHARMACIST MANAGER

Board Rule 16.2 (e) (f) and (g)

Name of Pharmacy

Address of

Pharmacy

Print Your Name as Pharmacist

Manager Attesting to Statements below

1.I certify that the Applicant has the ability to provide to the Board a record of a prescription drug order dispensed by the applicant to a resident of this state not later than 72 hours after a request for the record by the Board.

2.I certify that I am the pharmacist-manager and that I have read and understand the Vermont laws and rules relating to a non-resident pharmacy. http://vtprofessionals.org/opr1/pharmacists/rules.asp

3.I certify that during its regular hours of operation, but not fewer than six days per week, for a minimum of 40 hours per week, a toll-free telephone service is provided to facilitate communication between patients in this state and a pharmacist at the pharmacy who has access to the patients’ records. The toll-free number must be disclosed on the label affixed to each container of drugs dispensed to residents of this state; and evidence that during its regular hours of operation, but not fewer than six days per week, for a minimum of 40 hours per week, a toll-free telephone service is provided to facilitate communication between patients in this state and a pharmacist at the pharmacy who has access to the patients’ records. The toll-free number must be disclosed on the label affixed to each container of drugs dispensed to residents of this state.

Statement of Applicant

I certify, under the pains and penalties of perjury, that all information I have provided in this application is true and accurate. I understand that furnishing false information may constitute unprofessional conduct and result in the denial of my application or further disciplinary action. The maximum penalty for perjury is fifteen years in prison and/or a $10,000 fine. (13 V.S.A. §2901)

 

 

 

 

Signature of Pharmacist Manager

Date

 

 

 

Affix Prescription Label below or provide separately.

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