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How to use or fill out Part B Surrender form with our platform
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Click ‘Get Form’ to open the Part B Surrender form in the editor.
Begin by filling out Section A1, which requires your installation's name, address, and permit reference number. Ensure all details are accurate for a smooth process.
In Section A2, provide the operator's full name and registered office address. If applicable, include the trading name and company registration number.
For Section A3, designate a contact person who can answer questions regarding your application. Include their position, contact details, and email address.
Proceed to Section B1 to indicate whether you wish to surrender your permit in whole or in part. If partial surrender is selected, complete the table detailing which activities will cease operation.
In Section B2, specify the date operations will cease and any conditions that may require changes due to partial surrender.
Finally, review all sections for completeness before signing the declaration in Section C5. Ensure each operator signs if there are multiple individuals involved.
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Rules and Regulations on Controlled Substances in NYS
(i) pharmacy prescription number;. (ii) pharmacys National Identification Number;. (iii) patient name;. (iv) patient address, including street, city, state,
Every application for surrender of a license shall state the reason therefor; and, except in the case of an application for surrender of a license for a minor
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