NEVADA STATE BOARD OF PHARMACY LICENSE VERIFICATION
Send to State Board of Pharmacy for Completion: A separate letter is acceptable. Do not return with application unless it has been completed by the licensing agency.
NEVADA STATE BOARD OF PHARMACY 431 W Plumb Lane ? Reno, NV 89509 ? (775) 850-1440
LICENSE VERIFICATION
Name:
Address:
City:
State:
Zip:
I hereby authorize the
to furnish to the Nevada
State Board of Pharmacy, the information requested below.
Signature of Applicant
THIS FORM MUST BE FORWARDED TO THE HOME STATE LICENSING AGENCY FOR COMPLETION. DO NOT WRITE BELOW THIS LINE
License Number
License Status
Date License Issued Date License Expires
Has this license been
encumbered in any way? o Yes o No
Type of Encumbrance: (if any
o Revoked o Surrendered o Limited
o Suspended o Restricted
o Probation
Please attach copies of any pertinent legal documents
USE REVERSE SIDE OF THIS FORM FOR EXPLANATIONS IF NECESSARY
Has the applicant been convicted of any federal, state or local laws
relating to drug samples, wholesale or retail drug distribution, or
distribution of controlled substances? (If yes, please explain)
o Yes o No
Has the applicant furnished any false or fraudulent material in any
applications made in connection with drug manufacturing or distribution? (if yes, please explain)
o Yes o No
Have any inspections of the applicant resulted in deficient ratings?
(If yes, please explain)
o Yes o No
Has applicant met all licensing requirements of your state? (If no, please explain)
o Yes o No
Signature of State Official
Title
State
Date
State Seal
................
................
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