Follow the steps to successfully complete your application.

1. Press the ‘Get Form’ button to access the CT Application For A New In-State Pharmacy. This will allow you to download the form and open it in a suitable editor.
2. Begin by filling out the pharmacy information section. Provide the new pharmacy name, location address, telephone number, city, state, zip code, and email address to be used for all correspondence.
3. Next, include the Federal Employer Identification Number (FEIN) and select the type of pharmacy from the options listed, such as community, infusion therapy, long-term care, nuclear, or specialty.
4. Enter the name of the pharmacy manager and their Connecticut pharmacist license number. Indicate whether the pharmacy manager has appeared before the Commission of Pharmacy as a first-time manager.
5. Complete the owner information section by selecting the type of business (individual/sole proprietorship, corporation, limited liability company, partnership) and providing the owner's name, business address, telephone number, email address, and the city, state, zip code associated with the business.
6. Answer the question regarding any felony convictions for the applicant or any partners. If applicable, attach a supplementary statement detailing the convictions.
7. Fill in the pharmacy inspection contact information, including the contact person's name, title, telephone number, email address, and anticipated dates for construction, completion, inspection, and opening.
8. List the pharmacy hours and store hours for each day of the week.
9. Complete the certification section by printing your name and title, signing the form, and dating it to confirm the information provided is accurate and in compliance with regulatory requirements.
10. Once you have filled out all sections of the form, save any changes, and prepare to download, print, or share the form as needed.

Start completing your CT Application For A New In-State Pharmacy online today!