APPLICATION FOR LICENSURE
DISTRIBUTOR of LEGEND DRUGS or LEGEND DEVICES

Type of Application - Check All Appropriate Boxes:

Attach a copy of the final transaction documents for the sell, merger, acquisition, trade, transfer, etc. which effected the change in ownership.

License Sub-Types (see bottom of page for descriptions) - Check All Appropriate Boxes

Fee Schedule - As determined by the # of license sub-types checked in the above section, pay amount below will be charged:

Applicant Company Name:

d/b/a or trade name (if applicable):

Primary Distribution Location from which product is shipped:

Distribution Center Address:

Distribution City, State, Zip Code: , State Choose a state AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY , Zip Code

If 3PL used, c/o (Name of 3PL service provider):

Are additional 3PLs used for distribution? Check here if additional 3PLs are also used for distribution, Upload list of additional 3PLs with distribution addresses.
Upload Additional 3PL files here.

Type of Business Conducted: (Mark all that apply)

Sales Facilities Delivery (physically distributes)

Standard Distributor:
Not Applicable

Sub-categories (Mark all that apply):(Does not apply if "Standard Distributor" license sub-type is not marked above.)

Type of Business:

Individual(Proprietorship) Partnership LP Corporation LLC

Type of Ownership:

Individuals Corporately Owned Publicly Traded Non-Profit (Charitable) Privately Held

Ownership

List of Owners
INDIVIDUAL(S) - List the name and the percent of ownership held for each individual person possessing greater than 10% interest in the applicant.
CORPORATELY OWNED - List the name(s) of parent company(s).
PUBLICLY TRADED - Provide the trading symbol.
PRIVATELY HELD - List the name(s) of financial, investment, trust, etc entity(s).

FACILITIES LOCATED IN LOUISIANA ONLY:
CRIMINAL HISTORY RECORDS (background) CHECK (CHRck) is required for each individual owner(s) possession greater than 10% interest in the applicant company. Louisiana State Police application for CHRck is by online application platform. A submission link to the CHRck electronic application is available on the Board’s website.

State of Incorporation (or Formation):

Choose a state AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Manner of Distribution:

(mark all items that apply.)

Type of Product Distributed:

(mark all that apply)

OUT-OF-STATE FACILITIES ONLY: Is your facility located in Louisiana? NA- Applicant Facility Located in Louisiana
Current home state distributor (or manufacturer if applicable) license as issues by the state in which the applicant facility is located; attach copy of license.

License Number: Expiration Date:

Check here if the state in which the applicant is located does not require distributor (or manufacturer, if applicable) licensing AND a 3PL is used for the distribution; must submit a copy of correspondence from the licensing agency of the state in which the applicant is located indicating that no license is required along with a copy of the 3PL license from the state in which the 3PL is located.

Check here if the applicant is a legend device only distributor whose licensing agency of the state in which it is located does not require licensing; must submit a copy of correspondence from the licensing agency of the state in which the applicant is located indicating that no license in required. If the applicant is a manufacturer, submit a copy of an FDA establishment registration.

Upload Out-of-State Registrations here.

Company/Corporate Officers and Board of Directors:

Officers & Directors

List every state or territory, other than Louisiana, where the applicant holds a current license as a drug or device distributor. (Leave blank if only licensed in Louisiana)

Facility Contact Person:

Regulatory Contact Person:

Regulatory Contact is the same as Facility Contact Person

Designated Responsible Party:

Mailing Address for license/regulatory:

Same as Distribution AddressCheck this if mailing address is same as distribution address.

Mailing Address:

Mailing City, State, Zip: , Mailing State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY , Mailing Zip Code:

Business Location Address:

Check this if business address is same as distribution address. Same as Distribution Address OR Check this if business address is same as mailing address. Same as Mailing Address

Business Location Address:

Business City, State, Zip: , Business State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY , Business Zip Code:

NOTE: ALL LOCATIONS THAT DISTRIBUTE PRODUCT MUST BE SEPARATELY LICENSED.

Disciplinary Actions: (For applying facility location)

If the answer to any of the above questions is "Yes" please attach an explanation and any pertinent documentation related to the matter.

Application Certification: I hereby certify, (1) I, the undersigned, am a representative of the applicant authorized to execute on their behalf such documents as this; (2) by my name entered below, the applicant (a) will operate the facility in a manner prescribed by federal, state, and local laws and all rules promulgated by the Board, (b) assumes all responsibility for acts and/or omissions committed by any personnel employed by it, and (c) make certain personnel employed by the applicant have the appropriate education, training, and experience to assume responsibility for handling, distribution, and storage of legend drugs or devices; and (3) to the best of my knowledge and belief, the information provided in this application is true and correct in all respects. Authorization is hereby given to the Louisiana Board of Drug and Device Distributors or their agent to investigate the information contained in this application. It is understood that information provided in this application may be provided to other federal, state, or local government or enforcement agencies.

Name of Authorized Applicant Representative RESPONSIBLE for and SUBMITTING this application:
Title of Authorized Representative:
Date:

DISTRIBUTORS OF LEGEND DRUGS OR DEVICES
Sub-Types:

STANDARD DISTRIBUTOR
Description: Any person (entity) that sales or facilitates the delivery of legend drugs or legend devices to persons other than the consumer or patient; including, but not limited to, manufacturers, repackagers, own-label distributors, jobbers, retail pharmacy warehouses, pharmacies, brokers, agents, freight forwarders, ship chandlers, reverse distributors, compounders/503b, and nuclear pharmacies.

WHOLESALE DISTRIBUTOR
Description: Any person (entity) that sales or facilitates the delivery of drug product to persons other than the consumer or patient excluding, but not limited to. manufacturers. repackagers, third-party logistic providers, distributors of devices, medical gases, intravenous drugs for replenishment or irrigation, blood or blood ocmponents, radioactive drugs or biologicals, imaging drugs, homeopathic drugs, and compounded drugs.

THIRD-PARTY LOGISTICS PROVIDER
Description: Any person (entity) that provides or coordinates warehousing, facilitates the delivery of, or other logistic services for a legend drug or legend device interstate and intrastate commerce on behalf of a manufacturer, distributor, or dispenser of a legend drug or legend device but does not take ownership of the legend drug or legend device nor have responsibility to direct the sale or disposition of the legend drug or legend device.