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AFFIDAVIT for Out-of-State Pharmacy License
)SS.)
srArE or tln:rlla-
)COUNTY
t,
Lee Martin
hereby certify that the assertions in this Affidavit
are true and correct to the best of my knowledge and belief, and state as follows:
1. I am the Phramcist in Charge for
Roadrunner Pharmacy
(the
Pharmacy), and in that capacity, I am authorized to speak on the Pharmacy's behalf.2. I certify that upon licensure, the Pharmacy will not sell or ship compounded sterileproducts unto the state of Nevada, as indicated on the Pharmacy's application for a Nevada Out-of-State Pharmacy License.3. I understand and acknowledge that the Pharmacy and any of its Nevada-registered/licensed staff members may be subject to discipline by the Board if the Pharmacy sellsor ships any compounded sterile product into Nevada without first obtaining written authorizationfrom the Board to do so.4. I certify that if the Pharmacy ever decides to sell or ship any compounded sterileproduct into Nevada, the Pharmacy, through an authorized representative, will first notify theBoard and obtain written approvalto sell and ship such products into Nevada.5. I understand that if the Pharmacy seeks approval to sell or ship compounded sterileproduct into Nevada, an authorized representative of the Pharmacy may be required to appearbefore the Board to answer questions before such approval is granted.
FURTHER AFFIANT SAYETH NOT.
l, Lee Martin
, do hereby swear under penalty of perjury that the assertions of this
affidavit are true.
s /-./--C l^/'+---<2
SUBSCRIBED AND SWORN TO
before me, qnotary public this
JAcauelilEerwE ucbnffiry'l,lo{ry PuHic. Arizona
J1,, day of
,20 Ia
Name
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