information shall be required on a form supplied by the state board of pharmacy
from each person making application for a license as a distributor of dangerous
name, full physical business address (not a post office box), and telephone
||All trade, fictitious, or business names used by the
licensee (e.g. "doing business as" or "formerly known as"). Trade or business
names shall not be identical to the name used by another, unrelated drug
distributor permitted to purchase or sell drugs in this state.
telephone numbers, and the full names of contact persons for all facilities
used by the licensee for the storage, handling, and distribution of dangerous
drugs located in this state or used to distribute drugs into this state.
type of ownership or operation (i.e., sole proprietorship, partnership,
corporation, or government agency).
information for the owner(s) and/or operator(s) of the drug distributor:
||The full name, business address, social security number, and
date of birth of each partner. If the partner is not a natural person, each
business entity that is a partner having an ownership interest must be
disclosed on the application up to and through the entity that is owned by a
||The name of the partnership.
partnership's federal employer identification number.
||The full name, business address, social security number and
date of birth of the corporation's president, vice-president, secretary,
treasurer and chief executive officer, or any equivalent position. For a
publicly traded corporation that obtains a criminal records check waiver
pursuant to paragraph (A)(3) of rule 4729:6-2-03 of the Administrative Code, the full name, business address, social security number and date of birth of the corporate officers subject to a criminal records check as determined by the board's executive director or director's designee.
||The name or
names of the corporation.
||The state of
||The corporation's federal employer identification
||The name of the parent company, if
||If the corporation is not publicly traded on a major
stock exchange, the full name, business address, and social security number of
each shareholder owning ten percent or more of the voting stock of the
||For a sole proprietorship: the full name, business
address, social securitynumber, and date of
birth of the sole proprietor.
||For a government
agency: the full name, business address, social security number, and date of
birth of the agency director.
||If the entity
submitting an application for a distributor of dangerous drugs license is
located outside the boundaries of the state of Ohio, the licensing process
shall include an inquiry to the licensing authority of the state or
jurisdiction to determine if the entity possesses a current and valid license
to distribute dangerous drugs in that state or jurisdiction and any
disciplinary action, including actions pending, the licensing authority is
taking or may have taken against the entity. This information may be used to
determine if the business entity should be granted a license by the state board
of pharmacy. An entity located outside the boundaries of the state of Ohio that
is making application for licensure as a third-party logistics provider or
virtual wholesaler shall maintain verified-accredited wholesale distributors
(VAWD®) accreditation from the national association of boards of pharmacy
if the state where the entity resides does not license such entities.
applicable, proof of the entity's valid registration with the United States
food and drug administration and/or the United States drug enforcement
||Any information required on the application as
determined by the board.
||Any follow-up information as deemed necessary by the
board's executive director or the director's designee upon receipt of the