Florida Board of Nursing
PO Box 6330
Tallahassee, FL 32314
Phone: (850) 245-4125
1.
Name:
First Middle
Florida License #
Apt. No.
City
Physical Location:
Apt. No.
Zip
Country
Home/Cell Telephone (Input with dashes)
This address should be where you will be/are dispensing. If dispensing at more than one location please
attach an additional sheet with other locations.
City
State
Zip
Country
Work/Cell Telephone (Input with dashes)
Do Not Write in this Space
For Revenue Receipting Only
Dispensing Application for Advanced
Practice Registered Nurse (APRN)
Please complete this application in
its entirety prior to printing.
Last/Surname
Street/ P.O. Box
State
Mailing Address: (Give the address where mail and your license should be sent)
Street
Fax: (850) 617-6460
The fee of $100.00 must be paid in the form of a cashier's check or money order, made
payable to: DOH Florida Board of Nursing
Dispensing is defined as selling medicinal drugs to patients in the office. A
practitioner who writes prescriptions or provides complimentary samples is not a
"dispensing practitioner," and therefore does not need to register with the
department.
Do you have any additional pages attached?
Yes
No
Applicant's Signature
Date
This field cannot be typed. You must print out the application and sign it.
DH-MQA 1185, 10/18, Rule 64B9-4.011 FAC
MM/DD/YYYY
I certify that the information on this form is true and correct. I dispense medicinal drugs for a fee from my practice location
and I understand an annual inspection of my dispensing records will be conducted.
