ࡱ> '` ibjbjLULU C.?.?RRRRRRRflll8mmfJjpq(qqqrZ+s4_skmmmmmm$hRwrrwwRRqqP{{{wvRqRqk{wk{{ϋ|RRqo `5|$l@xKǏTJ]xb$R{sSt{t|iua{s{s{s${^{s{s{sJwwwwfj D,RC)fj RCfffRRRRRR State of Florida Department of Business and Professional Regulation Drugs, Devices, and Cosmetics Program Application for Exemption Registration Form No.: DBPR DDC 227 If you have any questions or need assistance in completing this application, please contact the Department of Business and Professional Regulation, Drugs, Devices, and Cosmetics Program, at 850.717.1800. Section I Application Type CHECK ONE OF THE APPLICATION TYPES  FORMCHECKBOX  New Exemption [3311/1020]  FORMCHECKBOX  Exemption Renewal [3311/2020] Current Exemption Number: _______________  FORMCHECKBOX  Exemption Amendment [3311/2020] Current Exemption Number: _______________  Section II Exemption Qualification Criteria CHECK THE APPLICABLE QUALIFICATION CRITERIA   FORMCHECKBOX  State, federal, or local governmental officer or employee  FORMCHECKBOX  Qualified person using prescription drugs for lawful  FORMCHECKBOX  research,  FORMCHECKBOX  teaching or  FORMCHECKBOX  testing (check each that applies); not for resale.  Section III Applicant Information ORGANIZATON / BUSINESS INFORMATION 1. Name of Organization / Business: 2. Mailing Address (Street and Number):  City: State:Zip Code: 3. Physical Address (Street and Number) - Where the drugs/gases will be received and related records stored):  City: State:Zip Code:  Section IV Qualified Person Information QUALIFIED PERSON USING PRESCRIPTION DRUGS Name:  EDUCATIONAL DATA  SELECT HIGHEST GRADE COMPLETEDHigh School College Graduate School FORMCHECKBOX  1  FORMCHECKBOX  2  FORMCHECKBOX  3  FORMCHECKBOX  4  FORMCHECKBOX  1  FORMCHECKBOX  2  FORMCHECKBOX  3  FORMCHECKBOX  4  FORMCHECKBOX  1  FORMCHECKBOX  2  FORMCHECKBOX  3  FORMCHECKBOX  4Name of College or UniversityLocation (City, State)Dates Attended (MM/YY to MM/YY)Did you GraduateMajor/Minor or Area of Study  FORMCHECKBOX  Yes  FORMCHECKBOX  No   FORMCHECKBOX  Yes  FORMCHECKBOX  No   FORMCHECKBOX  Yes  FORMCHECKBOX  No   FORMCHECKBOX  Yes  FORMCHECKBOX  No  RELATED TRAINING / COURSE WORK: (VOCATIONAL, TRADE, GOVERNMENTAL, BUSINESS, ARMED FORCES, ETC.) Name of SchoolLocation (City, State)Dates Attended (MM/YY to MM/YY)Training CompletedArea of Training or Study  FORMCHECKBOX  Yes  FORMCHECKBOX  No   FORMCHECKBOX  Yes  FORMCHECKBOX  No   FORMCHECKBOX  Yes  FORMCHECKBOX  No   FORMCHECKBOX  Yes  FORMCHECKBOX  No  EXPERIENCE Please summarize the qualified persons experience in working with (or using) prescription drugs for the purpose in which the prescription drugs are being used. For example, if the purpose for use of the prescription drugs is research, teaching, and testing, the summary and description should set out the qualified persons experience in using the prescription drugs research, teaching, and testing that qualifies the person for the exemption being sought.Summary and Description of Experience: Section V Purchasing Information PURCHASING INDIVIDUAL INFORMATION1. Name in which purchases will be made: 2. Does this person have a DEA Registration Number?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, provide: Registration No: _____________________ Expiration Date: ____________________  PURPOSE FOR USE3. Explain the conditions of the lawful research, teaching or testing purposes. Use additional pages if necessary.4. Name of Florida Licensed Supplier of the Prescription Drugs or GasesNameFlorida License Number5. List all the prescription drug(s) or gases required for the activity. Use additional page if necessary.Prescription Drug/Gas NameAnticipated Quantity Each PurchaseFrequency Section VI Application Contact PERSON TO CONTACT FOR QUESTIONS ABOUT APPLICATION 1. Name of Contact Person regarding questions for this application:  Address (Street and Number):Telephone Number:  City: State:Zip Code:  E-Mail Address: Fax Number (Optional):  Section VII - Affidavit AFFIDAVIT Each application for a license or renewal of a license issued by the Department of Business and Professional Regulation shall be signed under oath or affirmation by the applicant, or owner or chief executive of the applicant without the need for witnesses unless otherwise required by law. I hereby certify the following: The drugs/gases will be secured and access to the drugs/gases will be restricted to authorized individuals. The drugs are not for resale. I am the individual who will be responsible for prescription drugs received under any exemption letter pursuant to this application. I am empowered to execute this application as required by section 559.79, FS. I understand that my signature on this application has the same legal effect as if made under oath. All information contained on this application is true and correct. I understand that falsification of any information on this application may result in administrative action, including a fine, suspension or revocation of the exemption and potential criminal penalties. Signature: Date:Print Name:  Submit your application, any additional pages, and all required supporting documentation to: Drugs, Devices, and Cosmetics Program 1940 N. Monroe Street, Suite 26A Tallahassee, FL 32399-1047 850-717-1800     DBPR-DDC-227 - Application for Exemption Registration Eff. 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