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O. Box 45027 Newark New Jersey 07101 Exemption/Waiver Application Please print CLEARLY. You must answer all of the questions on this form. Name of pharmacy Pharmacy permit number Pharmacy address Street Address City State ZIP Code Telephone number NPI number include area code Name and title of person submitting application Application for Exemption Based on the following I request an exemption from the reporting requirements of the Prescription Monitoring Program The pharmacy does not dispense Schedule II III IV or V controlled dangerous substances or human . only to inpatients in a hospital long-term care or other facility in which the residents are provided with 24-hour nursing care. Financial hardship or other good cause prevents the pharmacy from electronically submitting required prescription information to the Division. Please provide a brief description below or submit a separate document detailing the reason s you are unable to comply with the electronic submission requirement ....

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232