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ADC VERIFIED PHARMACY PROGRAM

APPLICATION FORM
Upload limits

Upload each document as 10 MB or less. Facility photos must be 5 MB or less each, with up to 10 photos total. The full submission must stay within 40 MB, otherwise the server may reject the form and no values will be saved.

SECTION 1: BASIC INFORMATION

PHARMACIST INFORMATION

SECTION 2: REGULATORY INFORMATION / DOCUMENTATION CHECKLIST

Supported: DOC, PDF, JPG, PNG. Max 10 MB.
Supported: DOC, PDF, JPG, PNG. Max 10 MB.
Supported: DOC, PDF, JPG, PNG. Max 5 MB each, up to 10 files.
Supported: DOC, PDF, JPG, PNG. Max 10 MB.
Supported: DOC, DOCX, PDF, JPG, PNG. Max 10 MB each, up to 10 files.

SECTION 3: OPERATIONAL INFORMATION

Supported: DOC, PDF, JPG, PNG. Max 10 MB.
Note: Your business may be contacted for compliance confirmation.

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.

SECTION 6: FOR OFFICIAL USE ONLY