USVI Public Records

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P.O. Box 222995 Christiansted, VI 00822-2995 Tel: 340-643-8992 Email: BoardofPharmacy@doh.vi.gov VIRGIN ISLANDS BOARD OF PHARMACY Pharmacy Name: State License Number: License Expiration Date: Virgin Islands License Number: Virgin Islands License Expiration Date: Physical Address of Pharmacy: Mailing Address of Pharmacy (if different from Physical Address:) Pharmacy Website: Pharmacy Phone Number: Pharmacy DEA Number: Expiration Date: Pharmacy Fax Number: Check all appropriate categories of medications that will be shipped (must reconcile with State Board Inspection): C-II C-III C-IV C-V Non-controlled legend OTC Herbal Other (specify): ________________________________________ Check all appropriate: Compounded Sterile Products: Non-sterile Compounded Products: Injectable/IV Oral Ophthalmic Topical Other (specify):____________________ Other (specify):_____________________ Commercially manufactured products List the names of prescribers licensed to practice in the U.S. Virgin Islands that the products will be shipped to: List all the states that the pharmacy is currently allowed to ship to: Within the last 5 years, were there any deficiencies noted by the State Board of Pharmacy? ❑ Yes ❑ No If yes, explain: (use a separate sheet if additional space is needed and attach corrective measures) BACKGROUND INFORMATION – CURRENT PHARMACIST IN CHARGE CHECK ONE: ❑ P.I.C ❑ P.O.R. ❑ Manager Name: (First Middle Last) P.I.C. License Number: P.I.C. License Expiration Date: Email Address: Telephone Number (Direct): REGISTRATION APPLICATION TO SHIP MEDICATIONS TO THE UNITED STATES VIRGIN ISLANDS CHECK ONE: ❑ INITIAL APPLICATION ❑ RENEWAL APPLICATION (2024‐2026) CHECK ONE: ❑CENTRALIZED SERVICES ❑PHARMACY ❑WHOLESALER ❑DISTRIBUTOR ❑3PL The Virgin Islands Board of Pharmacy Non-Resident Pharmacy Application Revised 7/17 /2024 FILLABLE APPLICATION PLEASE TYPE Have you ever underwent a disciplinary hearing? ❑ Yes ❑ No ❑ N/A If yes, explain (use a separate sheet if additional space is needed) Have you ever been convicted of a felony or misdemeanor? ❑Yes ❑No If yes, explain (use separate sheet if additional space is needed) _______________________________________________ Have you ever been involved in a malpractice settlement? ❑ Yes ❑ No If yes: How many? ________ For what?_______________________________________________________________ What was the award? ______________________ What was the settlement? _______________________________ APPLICATION REQUIREMENTS By completing this registration form the applicant agrees to: 1. Notify the Virgin Islands Board of Pharmacy (V.I.B.O.P) when there is any change in P.I.C. within 10 business days. 2. Notify the V.I.B.O.P. in the event of changes in the pharmacy ownership within 10 business days. 3. Provide the V.I.B.O.P. with a current state pharmacy license, with all applications (new and renewals). 4. Provide the V.I.B.O.P with a copy of liability insurance and proof that coverage includes products shipped applicable to the activities being performed. to the U.S Virgin Islands, for all applications (new and renewals). 5. Comply with and in accordance to FEDERAL REGULATIONS UNDER 21 U.S.C.. 801-971 or any other regulation 6. Notify the V.I.B.O.P. of any changes shipping activities to the U.S.V.I. provided above including, but not limited to: additional prescribers, change in pharmacy location, schedules/categories of products shipped within 10 business days. 7. Ensure that only federally approved medications for use in the United States will be shipped. 8. Once completed, mail this original registration form along with: 1. Copy of current state pharmacy license; 2. Copy of P.I.C. pharmacist license; 3. Copy of DEA registration; 4. $1872.00 Registration fee (biennial) payable to “Government of the VI”; 5. Copy of current pharmacy's certificate of liability insurance; 6. Copy of state board inspection report & corrective measures if deficiencies are noted; and 7. Attach a cover letter with the name, email & telephone # for the individual who can address questions regarding this registration application. Mail to: VI Board of Pharmacy - PLHP P.O. Box 222995 Christiansted, VI 00822-2995 Tel: 340-643-8992 Email: BoardofPharmacy@doh.vi.gov VIRGIN ISLANDS BOARD OF PHARMACY P.O. Box 222995 Christiansted, VI 00822‐2995 NON-RESIDENT PHARMACY AFFIRMATION STATEMENT I hereby affirm under the penalties of perjury that the statements made in this registration application are true, complete and correct. I waive, for processing of this application, any confidential provisions concerning the information required to be provided. I further understand that non-compliance with any of the program requirements outlined above may result in revocation of our being allowed to ship medications into the U.S.V.I. Applicant: ________________________________ __________________________________ ____________ Print Sign Date Witness: ____________________________ ____________________________________ Print Sign Notary Seal Notary Public: ____________________________ ________________________________ Print Sign My Commission Expires: ___________________ IMPORTANT: Shipping of products to the U.S. Virgin Islands can proceed only after written approval from the Virgin Islands Board of Pharmacy. The Virgin Islands Board of Pharmacy Non Resident Pharmacy Application Revised 07/17/2024