LIMITED RETAIL DISTRIBUTOR OF MEDICAL GASES AND/OR ... 2025

1. Click ‘Get Form’ to open the application in the editor.
2. Begin by entering the 'Location of Facility' where distribution will take place. Fill in your company name, street address, city, state, zip code, and telephone number.
3. Provide your Federal Tax ID number and email address. Ensure the email is correct as it is necessary for receiving your permit.
4. Indicate if you have a parent company and specify the state of incorporation if applicable. Check all relevant boxes under 'Nature of Retail Business' to describe your operations.
5. List the types of prescription devices you intend to ship to New Hampshire residents by checking appropriate options.
6. Complete the section for the person to whom applications should be directed, including their name, title, and contact information.
7. Answer questions regarding past registrations or licenses and attach any required documentation as specified in the declaration section.
8. Finally, sign and date the application at the bottom before submitting it through our platform.

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