PAH KNOW YOUR CUSTOMER (KYC)

KNOW YOUR CUSTOMER (KYC)

DUE DILIGENCE FORM
GENERAL INFORMATION
Legal Business Name:*
Does your company use a Business DBA Name?*

YesNo
Business DBA Name:
DBA = Doing Business As
Phone Number:*
Fax Number:
Controlled Med Purchaser Name:*
Purchaser Email:*
Shipping Address:*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Is your Billing Address the same as your Shipping Address?*

YesNo
Billing Address:

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Number of Doctors:*
Average Number of Patients Seen Daily:*

Hours of Operation:

	Opening Time	Closing Time
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

DEA REGISTRANT(S)
DEA Registrant(s):*
Additional Person(s) Responsible for Signing "Schedule 2" Orders:
ADDITIONAL INFORMATION
1. Are you registered with the Controlled Substance Ordering System (CSOS)*

YesNo
Please provide email address registered with CSOS:
Controlled Substance Ordering System (CSOS) Email
2. Last inspection date by the DEA?*
(Date MM/DD/YYYY, unknown, N/A are all acceptable answers)
3. Does the facility administer/dispense medications to patients on site?*

YesNo
4. Do you take back controlled substances that already have been dispensed to patients?*

YesNo
Please explain in detail:
5. Are all applicable state and federal licenses current, and issued, for the registered address at which the practitioner is practicing?*

YesNo
6-A. To your knowledge, is/has the registrant(s), owner(s), officer(s), or licensed employee(s) currently under investigation by any State or Federal authority (Attorney General’s Office, licensing authority, DEA, FDA, US Attorney’s Office, etc.)?*

YesNo
Please explain:
6-B. To your knowledge, is/has the registrant(s), owner(s), officer(s), or licensed employee(s) ever been convicted of a crime related to the distribution of controlled substances or listed chemicals?*

YesNo
Please explain:
6-C. To your knowledge, is/has the registrant(s), owner(s), officer(s), or licensed employee(s) had a license or registration denied, revoked, or suspended by any licensing authority, including DEA, or been the subject of administrative or civil action by any such authority (consent agreement, memorandum of agreement, memorandum of understanding, order to show cause, or immediate suspension order)?*

YesNo
Please explain:
7. Legal name and title of person who oversees the Controlled Substance Inventory?*
8. Have you ever been cut-off from purchasing controlled substances from any supplier?*

YesNo
Please explain:
9. What controlled substances are you currently using /dispensing on site?*
10. Does the registrant maintain a log of all controlled substances administered and controlled substances wasted?*

YesNo
Please explain:
11. Does the facility have policies and procedures in place for security and handling of controlled substances?*

YesNo
Please explain:
12. Are all employees that handle controlled substances trained in these policies and procedures?*

YesNo
Please explain:
13. Does DEA registrant(s) operate any other businesses that require a DEA permit other than what has already been provided?*

YesNo
Provide DEA permit numbers:
REGULATORY COMPLIANCE STATEMENT
Full Name:*
(DEA License Holder)
Title:*
Authorized Representative Signature*

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Date*

MonthDayYear
Please upload a copy of your DEA license, State license, and any other relevant supporting documents.*

Cancelof
Select your Pharmsource Account Manager (if applicable):
FOR PHARMSOURCE ANIMAL HEALTH USE ONLY
1st Reviewed By: _________________________________ Date: _______________ Approved: ☐ Yes ☐ No
Compliance Review By: _____________________________ Date: ____________ Approved: ☐ Yes ☐ No
Should be Empty:

KNOW YOUR CUSTOMER (KYC)

GENERAL INFORMATION

DEA REGISTRANT(S)

ADDITIONAL INFORMATION

REGULATORY COMPLIANCE STATEMENT