ARSD 20:67:02:02. Required application information

Applicants must complete the following information as part of the application form: (1) The name, full business address, and telephone number of the applicant; (2) All trade or business names used by the applicant; (3) Address, telephone numbers, and the name of contact person for the facility used by the applicant for the storage, handling, and distribution of prescription drugs; (4) The type of ownership or operation, that is, partnership, corporation, or sole proprietorship; (5) The name of the owner or operator, or both, of the applicant, including: (a) If a person, the name of the person; (b) If a partnership, the name of each partner and the name of the partnership; (c) If a corporation, the name and title of each corporate officer and director, the corporate names, the name of the state of incorporation, and the name of any parent company; (d) If a sole proprietorship, the full name of the sole proprietor and the name of the business entity; (6) Statements pertaining to factors that may determine eligibility for licensure, including if, in the last seven years any of the following have occurred: (a) Any convictions of the applicant under any federal, state, or local laws relating to drug samples, wholesale or retail drug distribution, or distribution of controlled substances; (b) Any felony convictions of the applicant under federal, state, or local laws; (c) The applicant's past experience in the manufacture or distribution of prescription drugs, including controlled substances; (d) Suspension or revocation by federal, state, or local government of any license currently or previously held by the applicant for the manufacture or distribution of any drugs, including controlled substances; (7) A statement certifying that the applicant will operate in a manner prescribed by federal and state law and rules adopted by the board; (8) The type of distribution; (9) The type of products distributed; and (10) The type of entity to which the products are distributed.