ADC VERIFIED PHARMACY PROGRAM

SECTION 1: BASIC INFORMATION

SECTION 2: REGULATORY INFORMATION / DOCUMENTATION CHECKLIST

SECTION 3: OPERATIONAL INFORMATION

SECTION 4: VERIFICATION AND INSPECTION CONSENT

SECTION 5: DECLARATION AND SIGNATURE

I, the undersigned, declare that the information provided above is true and accurate to the best of my knowledge. I understand that this application does not guarantee approval and that additional verification, background checks, and site inspection may be required.