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Home > Application

NAPAC Application for Pharmacy / Health Content Site

This form must be filled out completely. Fields marked with an (*) are mandatory.

NAPAC Application for Pharmacy / Health Content Site
This form must be filled out completely. Fields marked with an (*) are mandatory.
Company Information:

Date

*Company
*D/B/A
*Website Address
*Your Name (First, Last)
*Your Title
*Company Phone
*Company Fax
*E-mail
Secondary E-mail
Toll-Free Customer Service Phone
Direct Customer Service Phone
Customer Service E-mail

If you operate a health content site and do not offer pharmaceuticals skip the next section

Pharmacy Information:
* Pharmacy Name
* Pharmacy Address
* Country
Canadian Province ( if applicable)
* Pharmacy Telephone
*Pharmacy Fax
*Pharmacy E-mail
Pharmacy License No(s)
Pharmacy State License(s)
Please select either "yes" or "no" for all of the following questions.
Do you offer Over the Counter (OTC) products for sale?		Yes No
Do you offer pharmaceutical products for sale?		Yes No
Do you offer health content on your site?		Yes No
Has your pharmacy license even been revoked?		Yes No
Has pharmacy license ever been suspended?		Yes No
Has your pharmacist license ever been revoked?		Yes No
Has your pharmacist license ever been suspended?		Yes No
Are you licensed in multiple states?		Yes No
Are you licensed in multiple Provinces (Canada Only)?		Yes No
Do you employ Certified Pharmacy Technicians?		Yes No
Do you offer consumers access a toll-free number?		Yes No
Do you offer consumers access to a direct dial number?		Yes No
Do you offer a customer service e-mail address?		Yes No
Do you offer your customer's a snail mail address?		Yes No
Do you require a valid prescription to dispense prescription drugs?		Yes No
Do you require an in-depth Medical History Form? (Canada Only)		Yes No
Is your website secure?		Yes No
Do you have a Privacy Policy in place?		Yes No
Do you protect patient information?		Yes No
Do you sell prescription drugs approved by the FDA?		Yes No
Do you disclose your shipping policy?		Yes No
Do you post a Privacy Policy?		Yes No
Do you post an "About Us" page?		Yes No
Do you post a list of all fees associated with the purchase of a prescription?		Yes No
Do you post a "Return Policy"?		Yes No
Do you answer complaints within a 24-hour period?		Yes No
Do accept telephone orders?		Yes No
Do you accept credit cards?		Yes No
Do you accept personal checks?		Yes No
Do you accept money orders?		Yes No

Please provide us with the links to the following pages on your website.
Privacy Policy	EX: (www.yourpharmacy.com/privacy.html)
Return Policy	EX: (www.yourpharmacy.com/return.html)
Contact page	EX: (www.yourpharmacy.com/contact.html)
About Us page	EX: (www.yourpharmacy.com/about.html)
Disclaimer page	EX:(www.yourpharmacy.com/disclaimer.html)
Medical History Form (if Canadian)	EX: (www.yourpharmacy.com/history.html)
FAQ page	EX: (www.yourpharmacy.com/questions.html)


A sample order will be placed through your system by NAPAC. This sample order will be sent in order to view your "Thank You" or "Order Confirmed" page.

Please review NAPAC Standards & Practices Guidelines before proceeding. Once you have reviewed NAPAC Standards & Practices Guidelines, you must review the additional terms and conditions listed below and then click on "I Agree" or I Disagree".

I agree to NAPAC Standards & Practices Guidelines. I agree to inform NAPAC if any license that I reported at time of application is suspended or revoked. I agree to allow NAPAC, their agents and/or representatives to review my site. I agree to forward copies of all licenses to NAPAC for review and confirmation. I agree to allow NAPAC to confirm any state, federal or provincial licenses that I have been granted? I understand that the investigative fee and on-site inspection fee is $10,000.00. I understand that an additional investigative fee of $5,000.00 is due and payable if my NAPAC membership is suspended and I wish to reapply for NAPAC membership. I understand that if my NAPAC membership is permanently suspended, I cannot reapply for NAPAC membership and I understand that my site will be identified on the NAPAC Official WebSite as "Permanently Suspended" for a period of one year from the time of suspension. If my site is suspended, I consent to the release of such information to inquiring consumers of the basis for any disciplinary action and/or suspension by NAPAC. I specifically waive any and all rights with respect to same.

If you agree with the above terms and conditions, you must click on "I Agree" to submit your application to NAPAC. A NAPAC representative will contact you within 2 business days to confirm the information submitted on this application.
Thank You For Your Application. NAPAC
I Agree with the Above Terms & Conditions. Reset The Form

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