Fillable Application for an Oral Therapeutic Pharmaceutical Agents (T.P.A.) (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Application for an Oral Therapeutic Pharmaceutical Agents (T.P.A.) (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey State Board of Optometrists
124 Halsey Street, 6th Floor, P.O. Box 45012
Newark, New Jersey 07101
(973) 504-6440
Application for an Oral Therapeutic Pharmaceutical Agents
(T.P.A.) Certication
A New Jersey optometrist must be licensed and certied in order to prescribe topical and/or oral medications. Under no circumstances
should a New Jersey optometrist prescribe topical and/or oral medications without meeting all the requirements of the certication
process, including the assignment of an oral medications (OM) number from the New Jersey State Board of Optometrists. A New
Jersey Controlled Dangerous Substance (C.D.S.) number and a federal Drug Enforcement Agency (D.E.A.) number are required to
prescribe controlled substances.
If you graduated from optometry school before 2005, and you have an active topical (T.P.A.) Certication, please see section “A” below.
If you graduated from optometry school after 2005, please see section “B” below.
If you graduated from optometry school before 2005, and/or you have a New Jersey optometry license without a topical T.P.A.
certication, please see section “C” below.
Section A: If you graduated prior to 2005, and you have an active topical T.P.A. certication, the following process will
pertain to you.
1. Required credentialing course:
You must complete a credentialing course as outlined in N.J.A.C. 13:38-4.3.
The credentialing course(s) as set forth in N.J.A.C. 13:38-4.3(b) shall be offered by a school that is accredited
by the U.S. Department of Education and the Council of Postsecondary Accreditation and approved by the New
Jersey State Board of Optometrists to ensure that the credentialing course(s) cover the topics in N.J.A.C. 13:38-4.3(b).
Courses that will meet the requirements are currently being offered by the State University of New York (SUNY)
College of Optometry and the Pennsylvania College of Optometry (P.C.O.) at Salus University.
2. Passing a written examination following the coursework:
You must pass a test at the conclusion of the required coursework to be eligible to apply for your orals certication.
N.J.A.C. 13:38-4.2(b)3, “Verication that the applicant has successfully completed the educational requirements set forth
in N.J.A.C. 13:38-4.3(a) and (b). The applicant shall obtain the required verication from the school where
the applicant completed the educational requirements.”
N.J.A.C. 13:38-4.2(b)4, “Verication of test scores that the applicant has successfully passed the examination
requirements as set forth in N.J.A.C. 13:38-4.3 and 4.4."
3. Apply to the New Jersey State Board of Optometrists for certication to prescribe oral medications:
After completing the orals course and successfully passing the test, you can download the application for an
oral T.P.A. certication at http://www.njconsumeraffairs.gov/optometry/ or send a written request for an application
to the New Jersey State Board of Optometrists, P.O. Box 45012, Newark, N.J. 07101.
4. Receive your New Jersey oral medications certicate:
Upon receipt of your application and completion of the application process, the Board will issue an oral T.P.A. certication
number (OM).
Upon issuance of the oral T.P.A. certication from the New Jersey State Board of Optometrists you will
have the authority to prescribe nonscheduled oral medications. Those medications would include
medications such as oral antibiotics. You are not authorized to prescribe any controlled medications (Class
III, IV and V) such as analgesics until you receive a New Jersey Controlled Dangerous Substance (C.D.S.)
number and a federal Drug Enforcement Agency (D.E.A.) number.
In order to obtain a federal D.E.A. number, you will need to apply and qualify for a New Jersey C.D.S. number.
You can obtain an application by going to the website for the Drug Control Unit at www.njconsumeraffairs.gov/
drug/dchome.htm or call (973) 504-6341.
* All licensed optometrists currently holding a Therapeutic Pharmaceutical Agents (T.P.A.) certication
to prescribe topical medications must renew the topical (TO) certication. The $250.00 T.P.A. renewal fee
for topical medications will be applied as payment for the oral (OM) certication fee once you qualify.
Therefore, at the time that you submit your application to prescribe oral medications you will only be
responsible for the $125.00 application fee if you renewed your topical certication.
5. Applying and receiving a D.E.A. number:
Upon receiving your oral medications certication, you will be eligible to apply for a New Jersey C.D.S. number and
then you may be eligible to apply for a federal D.E.A. number. Information concerning the application can be
found on the U.S. Department of Justice’s D.E.A. website: www.deadiversion.usdoj.gov.
The C.D.S. number and the D.E.A. number are not issued by the New Jersey State Board of Optometrists.
Please do not call the State Board with questions concerning the C.D.S. and the D.E.A. number applications.
Upon receiving your New Jersey C.D.S. number and the D.E.A. number, you will be authorized to prescribe all oral
medications as dened by N.J.S.A. 45:12-1.
Section B: If you graduated after 2005, the following process will pertain to you.
If you graduated after 2005, you are eligible to apply to the New Jersey State Board of Optometrists for an oral T.P.A.
certication number without any additional credentialing requirements.
1. Download an oral T.P.A. certication application at http://www.njconsumeraffairs.gov/optometry/ or send a written
request for an application to the New Jersey State Board of Optometrists, P.O. Box 45012, Newark, N.J. 07101.
2. Upon receipt of your application and completion of the application process, the Board will issue an oral T.P.A.
certication number (OM).
Upon issuance of the oral T.P.A. certication from the New Jersey State Board of Optometrists, you will
have the authority to prescribe nonscheduled oral medications. Those medications would include
medications such as oral antibiotics. You are not authorized to prescribe any controlled medications (Class
III, IV and V) such as analgesics until you receive a New Jersey C.D.S. number and a federal D.E.A. number.
In order to obtain a federal D.E.A. number, you will need to apply and qualify for a New Jersey C.D.S. number.
You can obtain an application by going to the website for the Drug Control Unit at www.njconsumeraffairs.gov/
drug/dchome.htm or call (973) 504-6341.
3. Upon receiving your oral medications certication, you will be eligible to apply for a New Jersey C.D.S.
number and then you may be eligible to apply for a federal D.E.A. number. Information concerning the application can be
found on the U.S. Department of Justice’s D.E.A. website: www.deadiversion.usdoj.gov.
The C.D.S. number and the D.E.A. number are not issued by the New Jersey State Board of Optometrists. Please do not
call the State Board with questions concerning the C.D.S. and the D.E.A. number applications.
Upon receiving your New Jersey C.D.S. number and the D.E.A. number, you will be authorized to prescribe all oral
medications as dened by N.J.S.A. 45:12-1.
Section C: If you graduated prior to 2005, or if you are a New Jersey licensed optometrist who does not hold a topical
T.P.A. certication regardless of the date of licensure, the following process will pertain to you.
1. Successfully pass the Comprehensive Topical Credential Course.
2. Successfully pass the Treatment and Management of Ocular Disease Examination administered by the National Board of
Examiners in Optometry.
3. Required credentialing course:
You must complete a credentialing course as outlined in N.J.A.C. 13:38-4.3.
The credentialing course(s) as set forth in N.J.A.C. 13:38-4.3(b) shall be offered by a school that is accredited
by the U.S. Department of Education and the Council of Postsecondary Accreditation and approved by the New Jersey
State Board of Optometrists to ensure that the credentialing course(s) cover the topics in N.J.A.C. 13:38-4.3(b).
Courses that will meet the requirements are currently being offered by the State University of New York (SUNY)
College of Optometry and the Pennsylvania College of Optometry (P.C.O.) at Salus University.
4. Passing a written examination following the coursework:
You must pass a test at the conclusion of the required coursework to be eligible to apply for your orals
certication.
N.J.A.C. 13:38-4.2(b)3 - “Verication that the applicant has successfully completed the educational requirements set
forth in N.J.A.C. 13:38-4.3(a) and (b). The applicant shall obtain the required verication from the school
where the applicant completed the educational requirements.”
N.J.A.C. 13:38-4.2(b)4 - “Verication of test scores that the applicant has successfully passed the examination requirements
as set forth in N.J.A.C. 13:38-4.3 and 4.4."
5. Apply to the New Jersey State Board of Optometrists for certication to prescribe oral medications:
After completing the orals course and successfully passing the test, you can download the application for an
oral T.P.A. certication at http://www.njconsumeraffairs.gov/optometry/ or send a written request for an application
to the New Jersey State Board of Optometrists, P.O. Box 45012, Newark, N.J. 07101.
6. Receive your New Jersey oral medications certicate:
Upon receipt of your application and completion of the application process, the Board will issue an oral T.P.A.
certication number (OM).
Upon issuance of the oral T.P.A. certication from the New Jersey State Board of Optometrists, you will
have the authority to prescribe nonscheduled oral medications. Those medications would include
medications such as oral antibiotics. You are not authorized to prescribe any controlled medications (Class
III, IV and V) such as analgesics until you receive a New Jersey C.D.S. number and a federal D.E.A. number.
In order to obtain a federal D.E.A. number, you will need to apply and qualify for a New Jersey C.D.S. number.
You can obtain an application by going to the website for the Drug Control Unit at www.njconsumeraffairs.gov/
drug/dchome.htm or call (973) 504-6341.
7. Applying and receiving a D.E.A. number:
Upon receiving your oral medications certication, you will be eligible to apply for a New Jersey C.D.S.
number and then you may be eligible to apply for a federal D.E.A. number. Information concerning the application can be
found on the U.S. Department of Justice’s D.E.A. website: www.deadiversion.usdoj.gov.
The C.D.S. number and the D.E.A. number are not issued by the New Jersey State Board of Optometrists.
Please do not call the State Board with questions concerning the C.D.S. and the D.E.A. number applications.
Upon receiving your New Jersey C.D.S. number and the D.E.A. number, you will be authorized to prescribe all oral
medications as dened by N.J.S.A. 45:12-1.
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey State Board of Optometrists
124 Halsey Street, 6th Floor, P.O. Box 45012
Newark, New Jersey 07101
(973) 504-6440
Application for an Oral T.P.A. Certication
A nonrefundable application ling fee of $125, in the form of a check or money order made out to the State of New Jersey, must be
submitted with this application. (Applicants should understand that if the application ling fee is paid with a personal check, and the check
is returned by the bank due to insufcient funds, the next step in the licensure or certication process will be delayed until the fee is paid.)
The Oral T.P.A. Certication fee is $250.00 if you are applying during the rst year of a biennial renewal period (between May 1st of every
odd year through April 30th of every even year). If you are applying for an Oral T.P.A. Certication during the second year of a biennial
renewal period (between May 1st of every even year through April 30th of every odd year), your Oral T.P.A. Certication fee will be
$125.00. The Oral T.P.A. Certication fee must be submitted in the form of a check or money order made out to the State of New Jersey.
The Division is precluded by law from disclosing to the public the place of residence of licensees or applicants, without their
consent. However, you are required to provide an address that may be released to the public in our directories or in response to
other requests (by putting a check in the appropriate box). If you provide your place of residence as your public address
of record, we will assume that you have consented to have that address be disclosed. If you do not consent to the disclosure of
your place of residence, you should provide an address of record other than your place of residence that may be released
to the public. One of your addresses must include a street, city, state and ZIP code.
Information that you provide on this application may be subject to public disclosure as required by the Open Public Records Act
(OPRA).
Please print clearly. You must answer all of the questions on this application.
Personal Information
1. Name Dr. ____________________________________________________________________ (________________________)
Last name First name Middle initial Maiden name
2. Address
Home: ______________________________________________________________________________________________
Street or P.O. Box City State ZIP code County
_____________________________________ ___________________________________
Telephone number (include area code) E-mail address (optional)
Mailing: ____________________________________________________________________________________________
Street or P.O. Box City State ZIP code County
Main ofce: _________________________________________________________________________________________
Street address City State ZIP code County
_____________________________________
Telephone number (include area code)
Branch 1 ofce address and telephone number ______________________________________________________________
Branch 2 ofce address and telephone number ______________________________________________________________
3. I have completed the educational credentialing requirements in Oral Pharmacology from the approved credentialing institution.
_______________________________________________________________________________________________________
Name of institution
on ________________________________________
Month Day Year
4. Are you licensed to use and prescribe therapeutic pharmaceutical agents (T.P.A.s) in any other state? Yes No
If “Yes,” please provide the information requested below:
State(s) ____________________________________________ T.P.A. Issue Date(s) __________________________________
PLEASE TYPE OR PRINT ALL OF THE REQUESTED INFORMATION (EXCEPT SIGNATURES).
Attach a clear, full-face passport-
style photograph (2˝x 2˝) of your
head and shoulders, taken within
the past six months.
A photo is required with each
application.
Do not use staples to attach the
photo.
5. Social Security Number
You must provide your Social Security number to the Board or Committee. Failure to do so will result in denial/nonrenewal of
licensure or certication.
*Social Security Number: __________ -____________ - ___________
*Pursuant to N.J.S.A. 54:50-24 et seq. of the New Jersey taxation law, N.J.S.A. 2A:17-56.44e of the New Jersey Child Support
Enforcement Law, Section 1128E(b)(2)A of the Social Security Act and 45 C.F.R. 60.7,60.8 and 60.9, the Board or Committee is
required to obtain your Social Security number. Pursuant to these authorities, the Board or Committee is also obligated to provide
your Social Security number to:
a. the Director of Taxation to assist in the administration and enforcement of any tax law, including for the purpose of reviewing
compliance with State tax law and updating and correcting tax records;
b. the Probation Division or any other agency responsible for child support enforcement, upon request; and
c. the National Practitioner Data Bank and the H.I.P. Data Bank, when reporting adverse actions relating to health care
professionals.
6. Citizenship / Immigration Status
Federal law limits the issuance or renewal of professional or occupational licenses or certicates to U.S. citizens or qualied aliens.
To comply with this federal law, check the appropriate box below which indicates your citizenship/immigration status. If you are not
a U.S. citizen, attach a copy of your alien registration card (front and back) or other documentation issued by the ofce of U.S.
Citizenship and Immigration Services (USCIS).
U.S. citizen
Alien lawfully admitted for permanent residence in U.S.
Other immigration status
Questions about your immigration status and whether or not it is a qualifying status under federal law should be directed to the
USCIS at: 1-800-375-5283.
7. Child Support
Please certify, under penalty of perjury, the following:
a. Do you currently have a child-support obligation? Yes No
(1) If “Yes,” are you in arrears in payment of said obligation?
Yes No
(2) If “Yes,” does the arrearage match or exceed the total amount payable for the past six months?
Yes No
b. Have you failed to provide any court-ordered health insurance coverage during the past six months? Yes No
c. Have you failed to respond to a subpoena relating to either a paternity or child-support proceeding? Yes No
d. Are you the subject of a child-support-related arrest warrant? Yes No
In accordance with N.J.S.A. 2A:17-56.44d, an answer of “Yes” to any of the questions a(1) through d will result in a denial of
licensure or certication. Furthermore, any false certication of the above may subject you to a penalty, including, but not limited
to, immediate revocation or suspension of licensure or certication.
___________________________________ ___________________________________ ________________________
Applicant’s name (please print) Applicant’s signature Date
click to sign
signature
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8. Illegal Use of Controlled Dangerous Substances
The question below pertains to the illegal use of controlled dangerous substances. Please read the denitions carefully. Your responses
will be treated condentially and retained separately. Please be aware that you have the right to elect not to answer this question if
you have reasonable cause to believe that answering may expose you to the possibility of criminal prosecution. In that event, you
may assert the Fifth Amendment privilege against self-incrimination. Any claim of Fifth Amendment privilege must be made in
good faith. If you choose to assert the Fifth Amendment, you must do so in writing. You must fully respond to all other questions on
the application. Your application for licensure or certication will be processed if you claim the Fifth Amendment privilege against
self-incrimination. You should be aware, however, that you may later be directed by the Attorney General to answer a question that
you have refused to answer on the basis on the Fifth Amendment, provided that the Attorney General rst grants you immunity
afforded by statutory law, (N.J.S.A. 45:1-20).
“Currently” does not mean on the day of, or even in the weeks or months preceding the completion of this application. Rather, it
means recently enough so that the use of drugs may have an ongoing impact on one’s functioning as a licensee, or within the previous
365 days, whichever is longer.
“Illegal use of controlled dangerous substance” means the use of a controlled dangerous substance obtained illegally (e.g. heroin
or cocaine) as well as the use of controlled dangerous substances which are not obtained pursuant to a valid prescription or not taken
in accordance with the directions of a licensed health care practitioner.
a. Are you currently engaged in the illegal use of controlled dangerous substances? (As stated above, “currently” is dened as
“recently enough… [to] have an ongoing impact…” or “within the previous 365 days,” whichever is longer.)
Yes No
If you answered “Yes,” are you currently participating in a supervised rehabilitation program or professional assistance program
that monitors you in order to assure that you are not engaging in the illegal use of controlled dangerous substances?
Yes No
_____________________________________________________ ___________________________________
Applicant’s signature Date
click to sign
signature
click to edit
9. Have you ever changed your name? Yes No
If “Yes,” please submit with this application a copy of the marriage certicate, divorce decree or court order.
10. Have you ever been summoned; arrested; taken into custody; indicted; tried; charged with; admitted into pre-trial intervention
(P.T.I.); or pled guilty to any violation of law, ordinance, felony, misdemeanor or disorderly persons offense, in New Jersey, any other
state, the District of Columbia or in any other jurisdiction? (Parking or speeding violations need not be disclosed, but motor vehicle
violations such as driving while impaired or intoxicated must be.) Yes No
11. Have you ever been convicted of any crime or offense under any circumstances? This includes, but is not limited to, a plea of guilty,
non vult, nolo contendere, no contest, or a nding of guilt by a judge or jury. Yes No
If “Yes,” provide a copy of the judgment of conviction and the release from parole or probation. Please provide a complete explanation.
(Attach additional sheets of paper to this application.)
12. Do you currently hold, or have you ever held a professional license or certicate of any kind in New Jersey, any other state, the
District of Columbia or in any other jurisdiction?
Yes No
If “Yes,” for each license or certicate held, provide the date(s) held and the number(s). If the license or certicate was issued under
a different name, please provide that name. ____________________________________________________________________
Last name First name Middle initial
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
13. Have you ever been disciplined or denied a professional license or certicate of any kind in New Jersey, any other state, the District
of Columbia or in any other jurisdiction? Yes No
14. Have you ever had a professional license or certicate of any type suspended, revoked or surrendered in New Jersey, any other state,
the District of Columbia or in any other jurisdiction? Yes No
15. Has any action (including the assessment of nes or other penalties) ever been taken against your professional practice by any agency
or certication board in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
16. Have you ever been named as a defendant in any litigation related to the practice of optometry or other professional practice in New
Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
17. Are you aware of any investigation pending against a professional license or certicate issued to you by a professional board in New
Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
18. Are there any criminal charges now pending against you in New Jersey, any other state, the District of Columbia or in any other
jurisdiction? Yes No
19. Have you ever been sanctioned by or is any action pending before any employer, association, society, or other professional group
related to the practice of optometry or other professional practice in New Jersey, any other state, the District of Columbia or in any
other jurisdiction? Yes No
If the answer to any of the above questions, numbers 13 through 19, is “Yes,” provide a complete explanation of the circumstances
leading to the action, and any supporting documentation, on separate sheets of paper.
AffidAvit
This afdavit is to be executed by the applicant before a notary public:
State of: _____________________________________________
County of: ___________________________________________
I, ___________________________________________ , in making this application to the New Jersey State Board of
Optometrists for licensure or certication under the provisions of Title 45 of the General Statutes of New Jersey and the Rules
of the New Jersey State Board of Optometrists, swear (or afrm) that I am the applicant and that all information provided in
connection with this application is true to the best of my knowledge and belief. I understand that any omissions, inaccuracies
or failure to make full disclosures may be deemed sufcient to deny licensure or certication or to withhold renewal of or
suspend or revoke a license or certicate issued by the Board.
I further swear (or afrm) that I have read N.J.S.A. 45:12-1 et seq., together with the Rules and Regulations of the
New Jersey State Board of Optometrists, N.J.A.C. 13:38-1.1, and fully understand that in receiving licensure or
certication from the Board, I bind myself to be governed by them.
Furthermore, I voluntarily consent to a thorough investigation of my present and past employment and other activities
for the purpose of verifying my qualications for licensure or certication. I further authorize all institutions, employers,
agencies and all governmental agencies and instrumentalities (local, state, federal or foreign) to release any information, les
or records requested by the Board.
_____________________________________________
Applicant’s signature
Sworn and subscribed to before me this _____________
day of _________________________ , ____________
Month Year
_____________________________________________
Name of Notary Public (please print)
_____________________________________________
Signature of Notary Public
Afx Seal Here
} ss.
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signature
click to edit
click to sign
signature
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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey State Board of Optometrists
P.O. Box 45012
Newark, New Jersey 07101
(973) 504-6440
CertifiCAtion And AuthorizAtion form
f
or A CriminAl history BACkground CheCk
Directions: Answer all of the questions on this form.
1. Name _________________________________________________________ ( ________________________)
Last First Middle Maiden Name
2. Address ___________________________________________________________________________________________
Street or P.O. Box City State ZIP code
3. Date of birth __ __ /__ __ /__ __ Sex: Male Female
Month Day Year
4. Social Security number _________/ _____ / ________
5. Have you completed the ngerprinting process for any Board or Committee of the New Jersey Division of Consumer
Affairs since November 2003?
Yes No
If “No,” you will receive a separate mailing from the Board or Committee regarding the criminal history record background
check process. No payment is necessary as of now.
If “Yes,” please provide the following information and follow the instructions outlined below:
_______________________________________________ _______________________________________________
Board or committee requiring the ngerprinting Month and year you were ngerprinted
If you were ngerprinted after November 2003 as part of the criminal history background process for licensure or
certification by any other Board or Committee of the New Jersey Division of Consumer Affairs (a background
check conducted for the Department of Education, another state agency or another state does not apply) you will not be
required to be ngerprinted a second time. However, the Division must perform a criminal history background check each time
you apply for licensure or certication. The fee for this service is $18.75. Payment should be made in the form of a check or
money order payable to the State of New Jersey and should accompany your application packet.
6. Have you ever been arrested and/or convicted of a crime or offense? (Minor trafc offenses such as a parking or speeding
violations need not be listed.)
Yes No
Every such conviction on record must be disclosed. A true copy of every police report, judgment of conviction, sentencing
order and termination of probation order, if applicable, must be submitted with this form. Any documents (including employer
or supervisor letters of reference, if applicable) which present clear and convincing evidence of rehabilitation must be submitted
with this form. Failure to follow these instructions may result in the denial of an initial application.
Note: Copies of judgments, sentencing and termination of probation orders may be obtained from the clerk of the county
where those orders, disposing of the conviction, were issued and led.
Your continuing responsibility to disclose convictions of crimes or offenses: You must notify the Board or Committee
within ve (5) business days if you are convicted of any crimes or offenses after this form has been completed.
Continuation on the reverse side ➨
Mr.
Mrs.
Ms.
Board or Committee
________________________
Ofcial Use Only
Resubmit
________________________
Ofcial Use Only
Dual License
License Type 1
________________________
Applicant’s Number
________________________
License Type 2
________________________
Applicant’s Number
________________________
CertifiCAtion
I, ______________________________________________, in making this application to the Board or Committee for
certication or licensure, certify that I am the applicant and that all of the information provided in connection with this
application is true to the best of my knowledge and belief. I understand that any omissions, inaccuracies or failure to make full
disclosures may be deemed sufcient to deny certication or licensure or to withhold renewal of or suspend or revoke a certicate
or license issued by the Board or Committee.
I voluntarily consent to a thorough investigation of my present and past employment and other activities for the purpose
of verifying my qualications for certication or licensure. I further authorize all institutions, employers, agencies and all
governmental agencies and instrumentalities (local, state, federal or foreign) to release any information, les or records
requested by the Board or Committee.
I certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are
willfully false, I am subject to punishment.
__________________________________________________________ _________________________________
Signature of applicant Date
Rev. 1/2/19
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Application for an Oral Therapeutic Pharmaceutical Agents (T.P.A.) (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 15 August 2020

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