Section 392-2-10-1 - Application for Registration The free clinic shall provide the following information on forms supplied by the board, along with such other information as the board may require. Applications will not be considered for approval until they are complete. Incomplete applications will be returned to the applicant.
1. The name, physical address, contact address, telephone number, email address and world wide web address of the free clinic, including the name contact address, telephone number and employer identification number of the private nonprofit corporation that owns and/or operates the free clinic; the name of the parent company, if any; the name, contact address and title of each corporate officer and director; a certificate of existence from the corporation's state of organization and, for corporations not organized under Maine law, a certificate of authority from the Maine Secretary of State.2. The hours of operation of the free clinic;3. The DEA number, if required;4. The name and license number of the pharmacist in charge of the free clinic;5. A scaled drawing and floor plan of the free clinic which details the usage of each area;6. Demonstration of compliance with the storage and security requirements of Chapter 15, Section 5 of the board's rules; and7. The fee required by Chapter 10 of the rules of the Department of Professional and Financial Regulation, Office of Licensing and Registration, entitled "Establishment of License Fees."02-392 C.M.R. ch. 2, § 10-1