Get A Permit Fee Of $100 Must Accompany This Application - State Of ...

Filling out the A Permit Fee Of $100 Must Accompany This Application is an essential step for users seeking a medical gas supplier permit. This guide provides clear and step-by-step instructions to help you complete the form online with confidence.

Follow the steps to successfully complete your application online.

1. Click ‘Get Form’ button to access the application form and open it in your preferred online editor.
2. Carefully fill in the name and/or doing business as (dba) along with the street address of your facility. Ensure you provide this information clearly in the designated fields.
3. Enter the mailing address for the facility, if different from the physical location. Make sure to complete all blanks; if any section does not apply to you, please enter 'N/A'.
4. In the next section, describe your business practices at this location. Check the appropriate box to indicate if you supply medical gas only on drug orders issued to patients, or if there are other services provided.
5. Provide the name of the facility manager and their email address in the relevant fields.
6. Enter the contact phone number for the facility, including area code.
7. Specify the operational hours for the facility, indicating which days it is open.
8. Select the type of ownership from the options provided: individual, partnership, or corporation.
9. Input the state of incorporation if applicable.
10. If the name of the partnership or corporation differs from your facility name, please enter it in the relevant field.
11. List the individual owners, partners, or corporate officers. If necessary, attach a separate page to include all names and titles.
12. Indicate whether the manager, owner, or business has been involved in any criminal charges or disciplinary actions in the last 12 months. If yes, provide details on a separate page.
13. Confirm whether your facility is located in another state. If so, attach a copy of the facility’s license from that state.
14. Finally, provide the name and title of the person responsible for the application, along with their signature and the date of signing.
15. After completing the form, review all entries for accuracy. Save your changes, and you may choose to download, print, or share the completed form as needed.

Complete your application online today to ensure a smooth permit renewal process.