PAH KNOW YOUR CUSTOMER (KYC)

  • KNOW YOUR CUSTOMER (KYC)

    DUE DILIGENCE FORM

  • GENERAL INFORMATION

  • Does your company use a Business DBA Name?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Is your Billing Address the same as your Shipping Address?*
  • Rows

  • DEA REGISTRANT(S)

  • ADDITIONAL INFORMATION

  • 1. Are you registered with the Controlled Substance Ordering System (CSOS)*
  • 3. Does the facility administer/dispense medications to patients on site?*
  • 4. Do you take back controlled substances that already have been dispensed to patients?*
  • 5. Are all applicable state and federal licenses current, and issued, for the registered address at which the practitioner is practicing?*
  • 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.)?*
  • 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?*
  • 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)?*
  • 8. Have you ever been cut-off from purchasing controlled substances from any supplier?*
  • 10. Does the registrant maintain a log of all controlled substances administered and controlled substances wasted?*
  • 11. Does the facility have policies and procedures in place for security and handling of controlled substances?*
  • 12. Are all employees that handle controlled substances trained in these policies and procedures?*
  • 13. Does DEA registrant(s) operate any other businesses that require a DEA permit other than what has already been provided?*

  • REGULATORY COMPLIANCE STATEMENT

  • Date*
     - -
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  • FOR PHARMSOURCE ANIMAL HEALTH USE ONLY

  • 1st Reviewed By: _________________________________ Date: _______________ Approved: ☐ Yes ☐ No

  • Compliance Review By: _____________________________ Date: ____________ Approved: ☐ Yes ☐ No
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