USVI Public Records

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Pharmacy Information Pharmacy Name Physical Address Street Address City State Zip Code Managing Officer Information Full Legal Name of Individual Title of Officer VI Pharmacist License # Date of Birth (mm/dd/yy) Physical Address Street Address City State Zip Code Mailing Address Street Address City State Zip Code Home Phone Number Cell Phone Number The ORIGINAL supplemental form and all required attachments shall be mailed to: Virgin Islands Department of Health, Office of Professional Licensure, P.O. Box 222995, Christiansted, VI 00822 Virgin Islands Board of Pharmacy Managing Officer Form Submit a separate form for EACH Managing Officer for the new pharmacy license. This form must be filled out completely and accurately. Failure to fill out the form completely will result in delay of licensure. If not applicable put N/A Each officer must provide a home (main address which will be considered the confidential address of record AND an alternate address which may be provided to the public. You may enter the same address in both address types. Each individual owner, managing officer, or partner must attach a copy of their current Driver's License or state-issued identification card. This application should be submitted with a NEW Pharmacy Application or Change in Ownership Pharmacy Application ONLY. To Add/Remove Managing Officers on an Existing Pharmacy, submit the Change of Managing Officer Form Email Address Public Address (Alternate Address to be Provided to the Public) - REQUIRED Street Address City State Zip Code License Type License # State Expiration Date EACH OF THE FOLLOWING QUESTIONS MUST BE ANSWERED BY THE OFFICER BEING ADDED: (circle appropriate answer) Yes* No a. Been Arrested? Yes* No b. Been Charged with a crime but not arrested? Yes* No c. Pled nolo contendere? Yes* No d. Pled Guilty? Yes* No e. Received deferred adjudication for a misdemeanor? Yes* No f. Received deferred adjudication for a felony? Yes* No g. Been convicted of a misdemeanor? Yes* No h. Been convicted of a felony? Yes* No If the individual holds any other professional and/or regulatory licenses, provide the following information below (Examples: Pharmacist in another state, Physician, Registered Nurse, etc) pending against you by a regulatory authority? (e.g., denial, surrender, revocation, reinstatement, suspension, fine, reprimand, probation, restriction). Include such information for ALL states and territories and for ALL regulated professions. *If you answered "yes" to question #1, include the name of the Board, licensing or disciplinary authority and the date of the Order, and, if applicable, the date of the termination of the condition and/or probation. 1. Have you been the subject of ANY professional disciplinary action or are such actions 2. For any criminal offense, including those pending appeal, have you ever: *If you answered "yes" to questions #2 A-H, include all offenses even those for which you are subject to deferred adjudication. (e.g., assault, theft, theft by check, driving while license suspended, possession of controlled substances, public intoxication, DWI, driving under the influence of drugs.) Yes No Yes No Yes* No Signature of Owner/Managing Officer Date THIS SIGNATURE MUST BE NOTARIZED. Subscribed and sworn before me this ______ day of ____________________, 20 _______ Seal Here Notary Public___________________________________________ My commission expires: _________________________________ offender in any state or territory? 4. Are you a registered sex offender or have you ever been required to register as a sex of Pharmacy as a pharmacist, pharmacist intern, or pharmacy technician? * If you answered "yes" to question #5, indicate the type of license, certification, or registration that you received, the dates of registration and the registration number. Have you ever been licensed, certified, or registered with another state or territory Board Statement of Notary Public Attest: I hereby attest that by submitting this form, I request to be listed as an Owner/Managing Officer of the above mentioned pharmacy license, and the foregoing statements on this form and those on the attachment(s) to this form are to the best of my knowledge true and correct and that they are given of my free will., I agree that any misstatement(s) or omission(s) as to material facts will constitute violation of and subject me to the penalties set forth in the Virgin Islands Pharmacy Practice Act and Rules. I agree to comply with the Virgin Islands Pharmacy Act and Rules. offense? 3. Have you been subject to a court ordered probation or confinement as related to any 5.