Iowa Board of Pharmacy

sue.mears@iowa.gov

400 SW 8th St Ste E Des Moines, IA 50309

515-281-5944

Petition for Waiver Form

Please review the Board's rules governing waivers and variances in 657 IAC Chapter 34 prior to filing a petition for waiver. Deadline for inclusion on the Board's agenda is two weeks prior to a Board meeting.

Licensee/Registrant Name

License/Registration No.:

Address Autocomplete

Address or Location

Direct Phone Number for Contact Person

Direct Email Address for Contact Person

List each rule you are requesting to be waived:

Describe specifically which requirements you are requesting to be waived

List the time period for which you are seeking a waiver. The start date must be a future date. An end date must be requested.

Have you previously requested a waiver of any of the rules listed above?

Yes

If so, what was the outcome?

If a prior petition for waiver was granted or denied, attach a copy of the Board's prior written ruling or correspondence.

For each rule you are requesting to be waived, provide the following explanations:

Explain why following the rule would pose an undue hardship:

Explain how waiving the rule may impact other people:

Explain how the rule is intended to protect the public health, safety, or welfare:

Explain how the public health, safety, or welfare can still be protected if the rule is waived:

Have you spoken to a Board compliance officer or other member of Board staff about your request?

Yes

If so, who?

Attach copies of any relevant email correspondence

Do you wish to participate in the Board meeting when this Petition will be considered?

Yes

Attach any relevant documentation to support your answers.

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First Name

Last Name

Choose how to sign

Draw Type

I hereby attest to the accuracy and truthfulness of the information contained herein.

Receipt

You will be provided with a Receipt upon submission.