If I am a physician, and unless otherwise noted within this application, I have never had a registration issued under either F.S. 458.309 or F.S. 459.005 suspended or revoked, I have an active Drug Enforcement Administration (DEA) registration, and I have never had a DEA number revoked, I have never had a license to prescribe, dispense, or administer a controlled substance denied, revoked, voluntarily relinquished, or otherwise encumbered due to final disciplinary action of the state or by any jurisdiction. Furthermore, I have a full, active and unencumbered medical license under Florida Statutes Chapter 456 or 459, and I shall practice at the clinic location identified above.
I have not been convicted of or plead guilty or no contendere to (regardless of adjudication) an offense that constitutes a felony for receipt of illicit and diverted drugs, including a controlled substance listed in Schedule I, Schedule II, Schedule III, Schedule IV or Schedule V of Section 893.03 of the Florida Statutes, or of any state or the United States in the past five years.
I agree to immediately inform Pinellas County Consumer Protection should I cease to be affiliated with the clinic, or if I no longer practice at this clinic location or if my license is encumbered.
Pursuant to Pinellas County Prescription Management Ordinance, Section 86, I authorize any law enforcement or code enforcement officer of the department designated by the County Administrator who is authorized by the head of that department access to inspect this facility registered under this Ordinance for proof of registration, at any reasonable hour, without notice.
I certify that the foregoing statements are all true and correct; that I have withheld no information that would affect the review or granting of this license; and that I as permittee will own, operate, and exercise control over the proposed or existing high prescribing health clinic, and in the manner described herein.
Under penalties of perjury, I declare that I have read the foregoing application and that the facts stated in it are true and that a person who knowingly makes a false declaration is guilty of the crime of perjury by false written declaration, a felony of the third degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084.