[Code of Federal Regulations] [Title 21, Volume 1] [Revised as of April 1, 2005] From the U.S. Government Printing Office via GPO Access [CITE: 21CFR1301.17] [Page 19-21] TITLE 21-FOOD AND DRUGS CHAPTER II--DRUG ENFORCEMENT ADMINISTRATION, DEPARTMENT OF JUSTICE PART 1301_REGISTRATION OF MANUFACTURERS, DISTRIBUTORS, AND DISPENSERS OF CONTROLLED SUBSTANCES--Table of Contents Sec. 1301.17 Special procedures for certain applications. (a) If, at the time of application for registration of a new pharmacy, the pharmacy has been issued a license from the appropriate State licensing agency, the applicant may include with his/her application an affidavit as to the existence of the State license in the following form: [[Page 20]] Affidavit for New Pharmacy I, --------------------, the -------------------- (Title of officer, official, partner, or other position) of -------------------- (Corporation, partnership, or sole proprietor), doing business as ------ -------------- (Store name) at -------------------- (Number and Street), -------------------- (City) ------------ (State) ------------ (Zip code), hereby certify that said store was issued a pharmacy permit No. -------- by the ---------------- (Board of Pharmacy or Licensing Agency) of the State of ------------ on ------------ (Date). This statement is submitted in order to obtain a Drug Enforcement Administration registration number. I understand that if any information is false, the Administration may immediately suspend the registration for this store and commence proceedings to revoke under 21 U.S.C. 824(a) because of the danger to public health and safety. I further understand that any false information contained in this affidavit may subject me personally and the above-named corporation/partnership/business to prosecution under 21 U.S.C. 843, the penalties for conviction of which include imprisonment for up to 4 years, a fine of not more than $30,000 or both. ________________________________________________________________________ Signature (Person who signs Application for Registration) State of________________________________________________________________ County of_______________________________________________________________ Subscribed to and sworn before me this -------- day of --------, 19------. ________________________________________________________________________ Notary Public (b) Whenever the ownership of a pharmacy is being transferred from one person to another, if the transferee owns at least one other pharmacy licensed in the same State as the one the ownership of which is being transferred, the transferee may apply for registration prior to the date of transfer. The Administrator may register the applicant and authorize him to obtain controlled substances at the time of transfer. Such registration shall not authorize the transferee to dispense controlled substances until the pharmacy has been issued a valid State license. The transferee shall include with his/her application the following affidavit: Affidavit for Transfer of Pharmacy I, --------------------, the -------------------- (Title of officer, official, partner or other position) of -------------------- (Corporation, partnership, or sole proprietor), doing business as ------ -------------- (Store name) hereby certify: (1) That said company was issued a pharmacy permit No.------------by the -------------------- (Board of Pharmacy of Licensing Agency) of the State of ------------ and a DEA Registration Number -------------------- for a pharmacy located at -------------------- (Number and Street) ---- -------- (City) ------------ (State) ------------ (Zip Code); and (2) That said company is acquiring the pharmacy business of -------- -------- (Name of Seller) doing business as--------------------with DEA Registration Number ------------ on or about ------------ (Date of Transfer) and that said company has applied (or will apply on ---------- -- (Date) for a pharmacy permit from the board of pharmacy (or licensing agency) of the State of ------------ to do business as ---------------- ---- (Store name) at -------------------- (Number and Street) ---------- ---------- (City) ------------ (State) ------------ (Zip Code). This statement is submitted in order to obtain a Drug Enforcement Administration registration number. I understand that if a DEA registration number is issued, the pharmacy may acquire controlled substances but may not dispense them until a pharmacy permit or license is issued by the State board of pharmacy or licensing agency. I understand that if any information is false, the Administration may immediately suspend the registration for this store and commence proceedings to revoke under 21 U.S.C. 824(a) because of the danger to public health and safety. I further understand that any false information contained in this affidavit may subject me personally to prosecution under 21 U.S.C. 843, the penalties for conviction of which include imprisonment for up to 4 years, a fine of not more than $30,000 or both. ________________________________________________________________________ Signature (Person who signs Application for Registration) State of________________________________________________________________ County of_______________________________________________________________ Subscribed to and sworn before me this----day of------------, 19-- --. ________________________________________________________________________ Notary Public (c) The Administrator shall follow the normal procedures for approving an application to verify the statements in the affidavit. If the statements prove to be false, the Administrator may revoke the registration on the basis of section 304(a)(1) of the Act (21 U.S.C. 824(a)(1)) and suspend the registration [[Page 21]] immediately by pending revocation on the basis of section 304(d) of the Act (21 U.S.C. 824(d)). At the same time, the Administrator may seize and place under seal all controlled substances possessed by the applicant under section 304(f) of the Act (21 U.S.C. 824(f)). Intentional misuse of the affidavit procedure may subject the applicant to prosecution for fraud under section 403(a)(4) of the Act (21 U.S.C. 843(a)(4)), and obtaining controlled substances through registration by fraudulent means may subject the applicant to prosecution under section 403(a)(3) of the Act (21 U.S.C. 843(a)(3)). The penalties for conviction of either offense include imprisonment for up to 4 years, a fine not exceeding $30,000 or both. [62 FR 13949, Mar. 24, 1997]