9. Interim Manager (if applicable)___________________________________________________________
10. Interim Manager License No.____________________________________________________________
11. Name of proposed MOR: ________________________
12. License number of the proposed MOR: _______________________________________
13. Has the proposed MOR met all the continuing education requirements of the MA Board of Registration
in Pharmacy for the last two years? Yes No
NABP ID: __________________________________________
14. Has the proposed MOR had: (1) any convictions related to the distribution of drugs (including samples);
(2) any felony convictions; (3) any suspension(s) or revocation(s) or other sanction(s) by federal, state or
local governmental agency of any license or registration currently or previously held by the proposed MOR
for the manufacture, distribution, or dispensing of any drugs, including controlled substances?
Yes No List and explain. (Attach additional sheets if necessary)
15. Have any applications for licensure been denied by any federal or state agency including any state boards of
pharmacy?
Yes No List and explain. (Attach additional sheets if necessary)
ATTESTATION OF INVENTORY OF CONTROLLED SUBSTANCES
We attest that a complete inventory of controlled substances in Schedules II through V has been completed and
signed by the outgoing MOR and the proposed MOR, and filed with the pharmacy’s controlled substance records.
We attest that all required Schedule VI drugs have been reported to MassPat.
OUTGOING MANAGER PROPOSED MANAGER*
_____________________________ _____________________________
Print Print
_____________________________ ______________________________
Signature Signature
____________________________ _______________________________
Date Date
* In the event the outgoing Manager of Record is unavailable due to death, serious illness, or termination for
inappropriate handling of controlled substances, a staff pharmacist may be authorized to sign the inventory,
provided the Board is notified at the time the application is submitted why the staff pharmacist is signing the
inventory.
Do not send a copy of the inventory to the Board. But, remember to keep a copy on file
in the event it should be requested by an inspector.
Revised: 5/10/19 Page 3 of 4
