Non-Resident Wholesale Distributor Registration Application

Revised 11/2021

9960 Mayland Drive, Suite 300

Henrico, Virginia 23233

(804) 367-4456 (Tel)

(804) 527-4472 (Fax)

pharmbd@dhp.virginia.gov

www.dhp.virginia.gov/pharmacy

APPLICATION FOR A NON-RESIDENT THIRD PARTY

LOGISTICS PROVIDER REGISTRATION

Check Appropriate Box(es):

New

$350.00

Change of Responsible Party

$65.00

Change of Ownership

$65.00

Change of Location

No Fee

Change of Tradename

No Fee

Reinstatement

Call Board

The required fees must accompany the application. Fees are nonrefundable.

Make check payable to “Treasurer of Virginia”.

Applicant—Please provide the information requested below. (Print or Type) Use full name not initials

Name of Firm

Federal Employer Identification Number (FEIN)

Business Address

Telephone Number

City

State

Zip Code

Name of Responsible Party

Email address for Responsible Party

Address

Telephone Number

City

State

Zip code

Social Security Number of Responsible Party

Current Virginia Registration Number (if applicable):

0242-

Name of contact person for firm

Telephone Number

Signature of Responsible Party

Date

IMPORTANT: Additional documents list found on page 3 of this application

If reinstatement, complete the following:

• Request for reinstatement is due to lapse of license suspension or revocation of license

• Has this facility acted as a third party logistics provider of prescription drugs or devices and shipped into

Virginia during the time the license was lapsed, suspended, or revoked?

Yes No

Please answer the following questions:

1. Records of drugs and devices shipped into Virginia are readily retrievable from other records: Yes No

2. A legible copy of this firm's current, unexpired, unrestricted license to possess and ship drugs and devices in its resident

state is included with this application. Yes No If no, explain.

FOR BOARD USE ONLY:

Date Received:

Check No:

Receipt No:

Application No:

Date Issued:

Registration Number:

0242-

Reviewed by:

Date Reviewed:

Non-Resident Third Party Logistics Provider Application Page 2

Revised 11/2021

OWNERSHIP TYPE—check one:

Corporation Partnership Individual Other

Name of ownership entity if different

from name on application:

Address:

Phone No.

City:

State:

Zip Code:

State(s) of incorporation

Name and address of

Registered Agent* in VA

*Each non-resident third party logistics provider shall designate a registered agent in Virginia for service of any notice or other legal

document. Any non-resident third party logistics provider that does not so designate a registered agent shall be deemed to have

designated the Secretary of the Commonwealth to be its true and lawful agent, upon who may be served all legal process in any action or

proceeding against such non-resident third party logistics provider. A copy of any such service of legal documents shall be mailed to the

non-resident third party logistics provider by the board by certified mail at the address of record.

List all other trade or business names used by this facility: (includes “is doing business as,”and “formerly known as”)

Name:

I do solemnly affirm that the information provided on this application is true and accurate to the best of my

knowledge. Furthermore, I agree to notify the board of any changes to the required information within 30 days of

such change.

Signature:

Print Name:

Date:

For affirmation by the responsible party:

I do solemnly affirm I am

• the primary contact person for the board and responsible for managing the third party logistics operations at

this location

• employed full time in a managerial position, actively engaged in daily operations of a third party logistics

provider, and present on a full-time basis at this location during normal business hours, except for time periods

when absent due to illness, family illness or death, vacation, or other authorized absence

• not a responsible party for any other third party logistics provider;

• knowledgeable about all policies and procedures pertaining to the operations of the third party logistics

provider and all applicable state and federal laws related to third party logistics providers.

Signature of Responsible Party:

Print Name:

Date:

Non-Resident Third Party Logistics Provider Application Page 3

Revised 11/2021

Please attach the following additional general information about the business:

1. A list of all states in which the entity is licensed to purchase, possess and ship prescription drugs and devices, and into which it ships

prescription drugs and devices.

2. A full description of the business, including the square footage, security and alarm system description, temperature and humidity control,

and other relevant information of the facility or warehouse space used for prescription drug and device storage and shipping.

Please attach the following additional information concerning ownership:

1. Type of ownership and name(s) of the owner of the entity, including

A. If an individual: The name, address, social security number or control number.

B. If a partnership: The name, address, and social security number or control number of each partner, name of partnership and

federal employer identification number.

C. If a corporation:

(1) The name and address of the corporation, federal employee identification number, state of incorporation, the name and address

of the resident agent of the corporation;

(2) The name, address, social security number or control number, and title of each corporate officer and director;

(3) For non-publicly held corporations, the name and address of each shareholder that owns ten (10) percent or more of the

outstanding stock of the corporation;

(4) The name, federal employer identification number, and state of incorporation of parent company.

D. If a sole proprietorship: Full name, address, and social security number or control number of the sole proprietor and the name and

federal employer identification number of the business entity.

E. If a limited liability company, the name and address of each member, the name and address of each manager, the name of the

limited liability company and federal employer identification number, the name and address of the resident agent of the limited

liability company, and the name of the state in which the limited liability company was organized.

2. A list of all disciplinary actions, to include date of action and parties to the action, imposed against the entity by state or federal

regulatory bodies, including any such actions against the responsible party, principals, owners, directors, or officers over the last seven

years;

3. An attestation providing a complete disclosure of any past criminal convictions and violations of the state and federal laws regarding

drugs or devices or an affirmation and attestation that the applicant has not been involved in, or convicted of, any criminal or prohibited

acts. Such attestation shall include principals, directors, officers, the responsible party or any shareholder who owns 10% or more of

outstanding stock in any non-publicly held corporation;

Please attach the following information concerning the person named as the responsible party:

1. A passport size and quality photograph taken within 30 days of submission of the application

2. A resume listing employment, occupations, or offices held for the past seven years including names, addresses, and telephone

numbers of the places listed and showing a minimum of two years of verifiable experience in a pharmacy or third party logistics

providers licensed in Virginia or another state, where the person’s responsibilities included, but were not limited to, managing or

supervising the recordkeeping, storage, and shipment for drugs or devices

3. A description of any involvement by the person with any business, including any investments, other than the ownership of stock in

publicly traded company or mutual fund, during the past 7 years, which manufactured, administered, prescribed, distributed, or stored

drugs and devices and any lawsuits, regulatory actions, or criminal convictions related to drug laws or laws concerning third party

logistics providers of prescription drugs in which such businesses were named as a party

4. A sworn statement or affirmation disclosing whether the person has a criminal conviction or is the subject of any pending criminal

charges within or outside the Commonwealth of Virginia.

5. A federal criminal history record check through Fieldprint. The Board may accept a federal criminal background check completed by

Fieldprint if it was obtained no more than 90 days prior to the date of submission of an application for registration with the Board. If it

has been longer than 90 days or the responsible party has never obtained this, a new federal criminal background check will need to

be obtained. The link to obtain this background check as well as other pertinent information regarding the requirements may be found

here: https://fieldprintusa.com/FBIHomePage.aspx?PostingID=540&ChannelID=264

Non-Resident Third Party Logistics Provider Application Page 4

Revised 11/2021

Please note that once results are provided to the responsible party, they MUST download the results and save the document within 30

days. The PDF document should then be sent in with this application. Some additional helpful information from Fieldprint is found

here: https://fieldprintusa.com/FBISubPage_FullWidth.aspx?ChannelID=272

6. Any additional information deemed by the board to be relevant to determining eligibility of a responsible party.

Requirements to be a Responsible Party:

1. The responsible party shall be the primary contact person for the board as designated by the wholesale distributor, nonresident

wholesale distributor, third-party logistics provider, or nonresident third-party logistics provider, who shall be responsible for managing

the wholesale distribution operations at that location;

2. The responsible party shall have a minimum of two years of verifiable experience in a pharmacy or wholesale distributor or third-party

logistics provider licensed, registered, or permitted in Virginia or another state where the person's responsibilities included managing

or supervising the recordkeeping, storage, and shipment for drugs or devices;

3. A person may only serve as the responsible party for one wholesale distributor license, nonresident wholesale distributor registration,

third-party logistics provider permit, or nonresident third-party logistics provider registration at any one time;

4. The responsible party shall be employed full time in a managerial position and actively engaged in daily operations of the wholesale

distributor, nonresident wholesale distributor, third-party logistics provider, or nonresident third-party logistics provider;

5. The responsible party shall be present on a full-time basis at the location of the wholesale distributor, nonresident wholesale distributor,

third-party logistics provider, or nonresident third-party logistics provider during normal business hours, except for time periods when

absent due to illness, family illness or death, vacation, or other authorized absence; and

6. The responsible party shall be aware of, and knowledgeable about, all policies and procedures pertaining to the operations of the

wholesale distributor, nonresident wholesale distributor, third-party logistics provider, or nonresident third-party logistics provider and

all applicable state and federal laws related to wholesale distribution of prescription drugs or the legal acts of a third-party logistics

provider.