Fillable Arizona State Board of Pharmacy FOR AGENCY USE (Arizona)

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Arizona State Board of Pharmacy FOR AGENCY USE (Arizona)

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The Arizona State Board of Pharmacy FOR AGENCY USE (Arizona) form is 1 page long and contains:

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  • 3 check-boxes
  • 27 other fields

Country of origin: US
File type: PDF

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Arizona State Board of Pharmacy
Physical Address: 1616 W. Adams, Suite 120, Phoenix, AZ 85007
Mailing Address: P.O. Box 18520 Phoenix, AZ 85005
Phone: 602-771-ASBP (2727) Fax: 602-771-2749
www.pharmacy.az.gov
FOR AGENCY USE ONLY
Fee: Receipt No.: Check No.: Check Date:
2.1.17
APPLICATION FOR CERTIFICATE OF FREE SALE / GOOD MANUFACTURING PRACTICE
Applicant must hold an AZ Manufacturer permit to be eligible to receive a Certificate of Free Sale or Good Manufacturing Practice. Certificates are $200.00 each contingent
upon an annual inspection. Inspection fees are calculated at Compliance Officer hourly rate multiplied by the number of hours required for inspection.
(Select all that apply)
CERTIFICATE OF FREE SALE CERTIFICATE OF GOOD MANUFACTURING PRACTICE
(AZ Manufacturer Permit Number)
(AZ Permit Expiration Date)
(FDA Number)
(FDA Expiration Date)
(Business Name)
(Country of Export)
(Street Address)
(City)
(State)
(Zip Code)
(Mailing Address)
(City)
(State)
(Zip Code)
(E-mail Address)
(Phone Number)
(Fax Number)
(Contact Person’s Name)
(Contact’s E-Mail Address)
(Contact’s Phone Number)
(Products to be Exported) Attach a copy of the label for each product listed – if the product is to be exported in bulk and a label is not available, include a certificate of
composition.
Attach additional pages if more space is needed.
Number of Initial Certificates
Desired
@ $200.
00 each =
Number of Copies Desired @ $10.00 each =
Total Cost of all Certificates Requested =
(Attestation)
I certify that I have read and understand the contents and requirements of A.R.S. § 32-1904B(16)(17) and R4-23-205,
regarding obtaining a Certificate of Free Sale / Good Manufacturing Practice.
(Signature) To the best of my knowledge and belief the foregoing application is true and current in all respects.
(Date)
$ 0.00
$ 0.00
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Arizona State Board of Pharmacy FOR AGENCY USE (Arizona)

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Completed 20 July 2020

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