:: AZBOP Online Applications ::

Instructions

Physical Location

Resident

Non-Resident

Secondary Type

Full Service

Non-Prescription

You will be required to provide the following to complete your application. You will have the opportunity to upload the documentation listed below during the application process. If you are unable to upload the required documents, please email them to Board staff or mail them to the mailing address below. At the end of this application, you will be required to pay the application fee by debit or credit card. If you wish to pay by check or money order, please complete and submit the PDF version of this application.

Applicable Statutes and Rules

Please familiarize yourself with the statutes and rules listed below.

Statutes

A.R.S. § 32-1927.02, 1929, 1930, 1931, 1933, 1939
A.R.S. § 32-1981 through 1985;1993 through 1996

Rules

A.A.C R4-23-601, 602, 605
A.A.C R4-23-607, 901 (non-resident)

The Board of Pharmacy’s statutes and rules are located at https://pharmacy.az.gov under the ‘Resources’ tab”

I have read and understand the statutes and rules.

Business Information

Business Name

FEIN

Physical Street Address

Physical Suite # (Please use appropriate prefix (Example: Suite 101, Apt. 101, #101, etc.))

Physical Zip Code

Physical City

Physical State

Physical County

Phone

Ext

Fax

Website

Check if mailing address is the same as above.

Street Address

Suite # (Please use appropriate prefix (Example: Suite 101, Apt. 101, #101, etc.))

Zip Code

City

State

Foreign Postal Code

County

Ownership Information

Name Of Owner(s)

Phone

Ext

Fax

Is this entity a corporation or partnership with officers or partners? If yes, provide the name, title and address of each officer or partner. You may enter this information here or attach a list later in the application process.

Yes

Is this application being submitted because of a change in ownership?

Yes

If yes, indicate the former owner's name, AZ permit number, and permit name.

Other Business Information

Regulatory Questions

Designated Respresentative Information

Name of Manager or Responsible Person

Email Address

Emergency Phone Number

Ext

Address

Zip Code

City

State

County

Designated Representative Attestation (Full Service Only)
I hereby attest that the above-referenced Designated Representative:
• Is at least twenty-one years of age;
• Is employed in a managerial level position;
• Is actively involved in the daily operation of the wholesale distribution of prescription-only drugs.
• Is physically present at the full-service wholesale permittee facility during regular business hours.
• Is a designated representative for only one full-service wholesale permittee.
• Does not have any criminal convictions under any federal, state or local laws relating to wholesale or retail prescription-only drug distribution or distribution of controlled substances.

Fingerprint Clearance Card Information

To obtain an Arizona Fingerprint Clearance Card, Designated Representatives may apply online at https://psp.azdps.gov/services/fccFormTriage For questions about the process, you may contact the Department of Public Safety (DPS) by calling 602.223.2279. DPS office hours are Monday through Friday, 8:00 am to 5:00 pm.

Applicants must provide the Board with a copy of their card. The Board will not receive a copy of the card from DPS.

For more information, please review DPS Fingerprint Clearance Card Frequently Asked Questions at azdps.gov/content/basic-page/108

Contact Information

For questions about the Wholesaler Permit Application or the permitting process, please contact the licensing team at [email protected] or 602.771.2727

Attachments

A $100,000 bond, line of credit or certificate of deposit

Plans or construction drawings showing facility size and security for the proposed business

Documentation of compliance with local zoning laws (Lease or Zoning Statement)

Designated representative's resume

A list of officers or partners, if applicable

A list of similar businesses, if applicable

Disciplinary Orders, if applicable

Denials letters, if applicable

A copy of home state permit

A $100,000 bond, line of credit or certificate of deposit

Designated representative’s resume indicating educational or experiential qualifications related to drug wholesale operation

A list of officers or partners, if applicable

A list of similar businesses, if applicable

Disciplinary orders, if applicable

Denials letters, if applicable

Review Your Information

Affirm And Submit

I declare under penalty of perjury under the laws of the state of Arizona that the information I have provided in this application is true and correct to the best of my knowledge.

E-Signature :

Date :

Please be advised of the following pursuant to Arizona Revised Statutes (A.R.S.) § 41-1030:

A.R.S. § 41-1030 (B)

An agency shall not base a licensing decision in whole or in part on a licensing requirement or condition that is not specifically authorized by statute, rule or state tribal gaming compact. A general grant of authority in statute does not constitute a basis for imposing a licensing requirement or condition unless a rule is made pursuant to that general grant of authority that specifically authorizes the requirement or condition.

A.R.S. § 41-1030 (D)

This section may be enforced in a private civil action and relief may be awarded against the state. The court may award reasonable attorney fees, damages and all fees associated with the license application to a party that prevails in an action against the state for a violation of this section.

A.R.S. § 41-1030 (E)

A state employee may not intentionally or knowingly violate this section. A violation of this section is cause for disciplinary action or dismissal pursuant to the Agency's adopted personnel policy.

A.R.S. § 41-1030 (F)

This section does not abrogate the immunity provided by section 12-820.01 or 12-820.02.

Application for Wholesaler Permit

Instructions

Instructions

Applicable Statutes and Rules

Business Information

Ownership Information

Other Business Information

Regulatory Questions

Designated Respresentative Information

Fingerprint Clearance Card Information

Contact Information

Attachments

Review Your Information

Affirm And Submit