Get Primary Wholesaler Form

This guide provides comprehensive instructions for users on how to fill out the Primary Wholesaler Form online, ensuring that each section is completed accurately. By following these steps, you will be able to efficiently submit your application without overlooking essential details.

Follow the steps to complete the Primary Wholesaler Form accurately.

1. Press the ‘Get Form’ button to access the Primary Wholesaler Form and open it in your preferred editor.
2. Begin by filling in the establishment (permitted) name in the designated field. This should be the formal name of your business as it appears on legal documents.
3. Provide the physical address of your establishment, including the street, suite number, city, and state. Make sure this information is accurate and up to date.
4. If applicable, enter your Florida Permit Number in the designated field to identify your establishment.
5. Answer the first question about whether your establishment is a member of an affiliated group by selecting 'YES' or 'NO'. If 'YES,' provide the names and addresses of all members of your affiliated group in the specified area.
6. Indicate whether your establishment and all affiliated group members agree to provide records of prescription drug purchases within 48 hours upon request. Select 'YES' or 'NO' based on your circumstances.
7. For the previous fiscal year, enter the total dollar volume of prescription drug purchases made by your establishment in the designated field. If you are claiming this financial data as a trade secret, make a note in the indicated area.
8. Input the total dollar volume of prescription drugs purchased directly from manufacturers in the specified section. Similar to the previous step, indicate if this information is a trade secret.
9. Calculate the quotient of question #3 divided by question #2 and record the result in the provided space.
10. Respond to whether your purchases include transfers from an affiliated group member by selecting 'YES,' 'NO,' or 'N/A.' If 'YES,' provide the required total dollar volumes for the affiliated group purchases.
11. Answer whether your establishment purchased drugs from at least 50 different drug manufacturers last year by selecting 'YES' or 'NO.' If 'YES,' compile and list these manufacturers.
12. Indicate whether you or your entire affiliated group have at least 250 employees. Select 'YES' or 'NO.'
13. Ensure the person authorized to bind the entire affiliated group signs the form, includes their printed name, title, and the date.
14. Lastly, provide the contact information for the person to reach out to for further clarifications, including telephone number and email address.
15. After completing all fields of the form, review your entries for accuracy. You can then save your changes, download the form, print it, or share it as needed.

Complete your Primary Wholesaler Form online today to ensure your compliance and streamline your business operations.