Form 08-0098 - Wholesale Drug Distributor Self-Inspection Report - Alaska State Board Of Pharmacy Page 4
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4ALASKA STATE BOARD OF PHARMACY
PAGE 4 OF 4
WHOLESALE DRUG DISTRIBUTOR SELF-INSPECTION REPORT
NOTE: If any areas on the self-inspection report were checked off as being in compliance, you must still send in the report. You then have 90 days
to bring those areas into compliance. A new report will be sent to you to fill out.
I, the consulting pharmacist, state that all the statements herein contained are each and all strictly true in every respect.
I understand that false or forged statements made in connection with this self-inspection report may be grounds for denial or revocation of the drug
room license.
Consulting Pharmacist:
Date:
SUBSCRIBED AND SWORN to before me this date:
, 20
Notary Public:
State:
Judicial District:
My Commission Expires:
(SEAL)
08-0098 (Rev. 5/98)
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