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Application for a Permit to Operate as an Out-of-State Pharmacy in ArkansasPART I: GENERAL INFORMATIONBusiness Name:DBA or name that will appear on your permit if different from Business Name above:Employer Identification Number:Physical Address of Applicant:Street:City:State:Zip:Telephone Number:Fax Number:Website:Mailing Address (Complete this section ONLY if different from the physical address above.):Street or PO Box:State:City:Zip:Person with whom the Board of Pharmacy may communicate regarding this application:Name:Position:Telephone:Email:Type of Pharmacy (check all that apply): Internet pharmacy Full line retail pharmacy Specialty pharmacy Nuclear pharmacy Mail order pharmacy Chain pharmacy Clinic Independent pharmacy Other Compounding pharmacy Please provide a description of your operation on a separate sheet.Controlled Substances you Plan to Provide (check all that apply): Schedule II Schedule III Schedule IVDEA Number: Schedule V Not Applicable Applied For Not NeededName of DEA Registrant:Please indicate the states in which the applicant is licensed or check “NONE”: ALAKAZCACOCTDE FLGAHIIDILINIA KSKYLAMEMDMAMI MNMSMOMTNENVNH NJNMNYNCNDOHOK ORPARISCSDTNTXFOR OFFICE USE ONLYLicense #: OSDate Issued:Fee Submitted:Check #:NONE UTVTVAWAWVWIWY

YES NOHas the applicant pharmacy ever been licensed in Arkansas? YES NOHas the applicant previously or currently shipped into Arkansas? YES NOIs this application made as a result of a change of ownership?If Yes, what is the name of the facility licensed by the Arkansas Board of Pharmacy?What is the permit number? (Example: OS00001)What is the expected closing date of the sale?Who was the previous owner?How long has the applicant been licensed as a pharmacy?yearsToll-free telephone number for Arkansas patients:How many hours per week is this line available?Hours of aturdaySundayHours (Express in terms of a.m. and p.m.)Total Hours / DayTotal for the week:Each out of state pharmacy doing business in Arkansas by dispensing and delivering or causing to be deliveredprescription drugs to Arkansas consumers shall designate a resident agent in Arkansas for service of process asrequired in Regulation 04-04-0001(j). You may call the AR Secretary of State's office at 501-682-1010 for assistancewith this. Please provide the name, address, city, state, and zip of your Arkansas Resident Agent below. Please alsoattach a copy of your registered agent certificate.PART II: APPLICANT HISTORYPlease answer each of the following questions by putting a check ( ) in the appropriate box on the right. You mustanswer each question with a “Yes” or “No” response as no other response is acceptable. All “Yes” answers MUST beexplained in detail in a separate SIGNED and NOTARIZED affidavit. The affidavit should include all relevant dates, andidentify the relevant jurisdiction and/or entity involved. Failure to disclose any of the requested information may result inthe denial of your application or other appropriate action.NOTE: If you answer “Yes” to any of the questions below and you have already submitted a detailed affidavit to the Arkansas StateBoard of Pharmacy explaining your response you need not submit another detailed affidavit. Please note the date of your previoussubmission next to the applicable question(s).Is the applicant currently under investigation in any state in which it is licensed?Has the applicant ever had any application for a license or permit refused or denied by anylicensing authority?Has the applicant ever been the subject of disciplinary action or been sanctioned by anylicensing authority?Has the applicant ever had a registration issued by a controlled substance authority revoked,suspended, surrendered, limited, or restricted?Is there any disciplinary action pending against the pharmacy (applicant) by any licensingjurisdiction, the USDA, Drug Enforcement Agency, or any state drug enforcement authority?Has the applicant ever been convicted of violating any federal, state or local law related to drugsamples, wholesale or retail drug distribution, or distribution of controlled substances?Has the applicant ever been convicted of violating any federal, state, or local law related to thepractice of pharmacy? YESYES NO NO YES NO YES NO YES NO YES NO YES NOOut of State Pharmacy Application – Revised January 2020: Page 2

Have any of the applicant owners, officers, directors, or stockholders ever been convicted of afelony or crime involving the practice of pharmacy? (If the business is a corporation, you neednot include stockholders in this question unless they currently serve as officers or directors ofthe applicant business, or own more than twenty percent (20%) of the company stock.)Has any sanction or disciplinary action been taken regarding any license, permit or registrationissued to the applicant, officers, directors, partners or stockholders involving drug distribution?(If the business is a corporation, you need not include stockholders in this question unless theycurrently serve as officers or directors of the applicant business, or own more than twentypercent (20%) of the company stock.)Are there any charges pending against the applicant, officers, directors, partners orstockholders involving drug distribution? (If the business is a corporation, you need not includestockholders in this question unless they currently serve as officers or directors of the applicantbusiness, or own more than twenty percent (20%) of the company stock.) YES NO YES NO YES NOPART III: PERSONNELList all individuals filling prescriptions or performing any function considered to be the practice of pharmacy for thisbusiness. You may attach additional sheets if needed. YOU MUST NAME A PHARMACIST IN CHARGE.NameLicense #Hours/WeekDegreePharmacist in Charge:Arkansas Pharmacist in Charge : For the Arkansas pharmacist, please provide the Arkansas license number.If the pharmacist is reciprocating to Arkansas, please check one of the following months to indicate theexpected appearance before the Arkansas Board:February June October Other Pharmacists: The Arkansas pharmacist in charge must hold an Arkansas pharmacist license and shall be an employee (not aconsultant) of the applicant pharmacy who is present at the physical location stated on the application. The Arkansaspharmacist in charge shall work at least fifty percent (50%) of the hours the pharmacy is open up to a maximum oftwenty (20) hour per week being required. The Arkansas pharmacist in charge need not be the same person as thepharmacist in charge of the pharmacy. The Arkansas pharmacist in charge is responsible for compliance with Arkansasregulations as they pertain to the shipment of drugs to Arkansas patients and for receiving and maintaining publicationsdistributed by the Arkansas State Board of Pharmacy.PART IV: BUSINESS OWNERSHIP Select the appropriate form of ownership from the choices below, and then go to the next appropriate section.Sole Proprietorship (Go to A)General Partnership (Go to B) Corporation (Go to C)Limited Partnership (Go to B) LLC (Go to C)LLP (Go to B) Other (Please explain)A. Please provide the name, and the address of the owner of this company:Go to Item D.B. Partnership Name, if different from Applicant name listed on Page 1.In the space provided below, please provide the names, addresses and percentage ownership of all partners/members.You may attach a list of partners/members if there is not enough space.Go to Item D.Out of State Pharmacy Application – Revised January 2020: Page 3

C. Corporation Name, if different from Applicant name listed on Page 1. Check if Subchapter S CorporationState of Incorporation/Formation:Is this corporation publicly traded?Is this corporation a wholly owned subsidiary of another company or corporation?What is the name of the parent company? YESYES NO NOPlease provide the names, addresses and percentage ownership of all of the owners of this corporation. You mayuse a separate sheet if you need more space.Go to Item D.D. Please provide the names and titles of the officers or directors of this company.President:Vice President:Secretary:Treasurer:Specify additional titles below:If you need additional space for the corporate officer list, please attach the list as a separate document.E. Is there any non-profit interest in your pharmacy? YES NOF. Any interest in or relationship with a not-for-profit hospital? YES NOIf YES, to either question E or F, please explain:V. OPERATIONSPlease respond to the following statements/questions on the bottom of this sheet and the back of it. You can attach aseparate sheet if you need more space to respond.A. Why is your facility seeking licensure in Arkansas?B. Describe the nature of your operation in detail.Out of State Pharmacy Application – Revised January 2020: Page 4

C. Describe in detail how the pharmacy will comply with regulation 09-00-0001 – patient counseling, patient profile, druguse evaluation.D. Describe in detail how the pharmacy will ensure patient freedom of choice of providers.E. How will your pharmacy and the pharmacist in charge ensure that patient confidentiality is maintained?F. Describe the computer hardware and software that will be used in the pharmacy.G. How does your pharmacy ensure a valid patient/physician relationship?H. Does the pharmacy have a sales/marketing staff?If Yes, what are their roles? YES NOI. YES NO YES NO YES NO YES NO YES NODoes the pharmacy have a website?If Yes, do you provide referrals to physicians or other practitioners?If Yes, please explain your relationship with these physicians and practitioners.J. Does the pharmacy fill orders received on the pharmacy’s website?K. Do you provide links to websites that provide referrals to physicians, practitioners or otherorganizations?If Yes, please describe your relationship with these other websites.L. Do you process prescriptions for insurance companies and PBMs?If Yes, please name those companies.Out of State Pharmacy Application – Revised January 2020: Page 5