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Florida Health Care Clinic Establishment License Application

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Florida Health Care Clinic Establishment License Application Powered By Docstoc
					                            Florida Department of Business and Professional Regulation
                                      Drugs, Devices, and Cosmetics Program
                               1940 North Monroe Street, Tallahassee FL 32399-0783
                                               Phone 850.717.1800


                     HEALTH CARE CLINIC ESTABLISHMENT (HCCE) APPLICATION
This application form provides information as required by the Florida Drug and Cosmetic Act, Chapter
499, Florida Statutes (F.S.). Only a completed application signed by the authorized representative of the
applicant will be processed. Additional information may be required for an application to be considered
complete. The application must be filled out in its entirety. Failure to do so will result in a delay in the
permitting process, and may result in denial of this application.

                            Submit $255.00 fee with application-made payable to the
                          Florida Department of Business and Professional Regulation

Please select one application type.             ( ) New Application ( ) Change of Ownership
1. Federal Tax Identification Number          2. Corporate or Legal Name of Business Entity

3. Doing Business As (d/b/a name that will appear on permit and invoices)

4. Mailing Address

City                                   State                               Zip

5. Physical Address                                                        Telephone

City                                   State         Zip              County

6. Who should the department contact with questions regarding this application?
Name (Last, First, MI)

Address                                                                  Telephone Number

City                                  State                              Zip

E-Mail Address (Optional)

7. Designated Qualifying Practitioner
Name (Last, First, MI)                                     Telephone Number         License # With Prefix

Residence Address-Must be different than #5                City                     State        Zip

E-Mail Address (Optional)

Type of License Held-Please check
          Health Care Practitioner Defined in Section 456.01, F.S.
          Veterinarian Licensed Under Chapter 474, F.S.
Signature of Designated Qualifying Practitioner-

Rule 64F-12.015, F.A.C.                             Page 1 of 3
8. Operating Hours
 M____ : ____ am/pm To ____ : ____ am/pm                        F____ : ____ am/pm To ____ : ____ am/pm
TU____ : ____ am/pm To ____ : ____ am/pm                      SA____ : ____ am/pm To ____ : ____ am/pm
W____ : ____ am/pm To ____ : ____ am/pm                       SU____ : ____ am/pm To ____ : ____ am/pm
TH____ : ____ am/pm To ____ : ____ am/pm
9. Ownership Information-Indicate your business entity type by selecting one of the following:
        CORPORATION-Please select one of the following: ( )Publicly Held ( )Closely Held
Please list the name and title of each corporate officer and director, the corporate names, and the name of the
state of incorporation in the spaces provided below. Use additional sheets if necessary.
          LIMITED LIABILITY COMPANY
Please list the name of each member, the name of each manager, and the name of the state in which the limited
liability company was organized in the spaces provided below. Use additional sheets if necessary.
       NOT FOR PROFIT CORPORATION
Please list the name of the director and the five most senior corporate officers’ name and title and the state of
incorporation in the spaces provided below.
        PARTNERSHIP-INCLUDING LLP AND LP
Please list the name of each partner in the spaces provided below.
       PROFESSIONAL CORPORATION OR PROFESSIONAL LLC
Please list the director, the five most senior corporate officers with title. Provide the state of incorporation or
organization, as applicable, and the registered agent in the spaces provided below.
        SOLE PROPRIETORSHIP
Please list the owner’s name in the spaces provided below.
        Government
          Corporate Officers, Directors, Members, Managers, Partners, Owners                     Position/Title




State of Incorporation-
State LLC was organized in-
Registered Agent-
Corporate Names-



Rule 64F-12.015, F.A.C.                               Page 2 of 3
10. Has the applicant or designated qualifying practitioner been fined or disciplined by a regulatory
agency in any state (including Florida) for any offense that would constitute a violation of chapters 456,
465, 474, 499, 899, F.S., related to the distribution, possession, administration, or dispensing of
prescription drugs?

Yes                          No
                                               (If yes, explain on a separate sheet providing accurate details)
11. Has the applicant or designated qualifying practitioner ever entered a plea to, been convicted or
found guilty of, any felony under a federal, state (including Florida), or local law related to the
distribution, possession, administration or dispensing of prescription drugs? Include all cases where a
guilty, nolo contendere or no contest plea was entered, whether or not adjudication was withheld.

Yes                          No
                                               (If yes, explain on a separate sheet providing accurate details)

12. Has the applicant or designated qualifying practitioner had any current or previous permit of license
suspended or revoked which was issued by a federal, state or local governmental agency relating to the
manufacturing, distributing, prescribing, dispensing, or administration of prescription drugs?

Yes                          No                (If yes, explain on a separate sheet providing accurate details)

13. Has the applicant or designated qualifying practitioner been denied a permit or license in any state
(including Florida) related to an activity regulated under chapters 465, 499, 893, F.S.?

Yes                          No                (If yes, explain on a separate sheet providing accurate details)



AFFIDAVIT: I, ___________________________________, on behalf of the applicant
                         (Print Name)
           business, do solemnly swear or affirm that I understand that the HCCE and the designated
           qualifying practitioner are required to comply with the provisions of Chapter 499, F.S. and
           Rule 64F-12, Florida Administrative Code. I further affirm the information submitted to the
           department on this application and any attachments thereto are true and correct.


                  ___________________________________
                  Signature of Owner or Company Officer*

                  ___________________________________
                             Title

                  ___________________________________
                             Date

*If signed by someone other than an owner or officer, you must submit a letter for the signer to bind the
applicant.




Rule 64F-12.015, F.A.C.                         Page 3 of 3

				
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