Sole Proprietorship Ownership Form
Sole Proprietorship Ownership Form Virgin Islands Board of Pharmacy The ORIGINAL supplemental form and all required attachments shall be mailed to: Virgin Islands Dept. of Health, Office of Professional Licensure, P.O. Box 222995, Christiansted, VI 00822 Name of Individual Owner Physical Address Street Address City State Zip Code Mailing Address Street Address City State Zip Code Home Phone Number Cell Phone Number Email Address If you prefer the home address to remain confidential, provide an Address of Public Record below: Address of Public Record Street Address City State Zip Code ATTEST: I hereby attest that the foregoing statements or those on any attachment(s) to this form are to the best of my knowledge true and correct and that they are all given of my free will. I agree that any misstatement(s) or omissions(s) as to material facts will constitute violation of and subject me to penalties set forth in the Virgin Islands Board of Pharmacy Practice Act. I agree to comply with the Virgin Islands Practice Act and Rules and Regs. …
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Sole Proprietorship Ownership Form Virgin Islands Board of Pharmacy The ORIGINAL supplemental form and all required attachments shall be mailed to: Virgin Islands Dept. of Health, Office of Professional Licensure, P.O. Box 222995, Christiansted, VI 00822 Name of Individual Owner Physical Address Street Address City State Zip Code Mailing Address Street Address City State Zip Code Home Phone Number Cell Phone Number Email Address If you prefer the home address to remain confidential, provide an Address of Public Record below: Address of Public Record Street Address City State Zip Code ATTEST: I hereby attest that the foregoing statements or those on any attachment(s) to this form are to the best of my knowledge true and correct and that they are all given of my free will. I agree that any misstatement(s) or omissions(s) as to material facts will constitute violation of and subject me to penalties set forth in the Virgin Islands Board of Pharmacy Practice Act. I agree to comply with the Virgin Islands Practice Act and Rules and Regs. Signature of Owner Date THIS SIGNATURE MUST BE NOTARIZED Statement of Notary Public Subscribed and sworn before me this ______ day of ____________________, 20 _______ Seal Here Notary Public___________________________________________ My Commission Expires: _________________________________