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f. Proof that any person who will be prescribing or administering controlled <br />substances at the pain management clinic has a valid and current <br />controlled substance registration number issued by the United States <br />Department of Justice, Drug Enforcement Administration, including the <br />controlled substance registration number for each such person; <br />g. <br />A sworn statement certifying that within the ten (10) years prior to submittal <br />of the application, neither the pain management clinic, nor any person <br />identified pursuant to subsections b, c or d above, has been found by any <br />county or municipal board, commission or council, or by any state or <br />federal court, or by any state or federal regulatory body, to have acted with <br />respect to controlled substances in violation of applicable law; and <br />h. A sworn statement certifying that the pain management clinic, and every <br />other clinic owned or operated by any person identified pursuant to <br />subsections b, c or d above, will, during the term of the permit, be operated <br />in compliance with applicable law. <br />(3) <br />Abbreviated Application for Qualified Pain Management Clinics. In lieu of <br />completing the application form described in subsection (2), a qualified <br />pain management clinic requesting issuance of a pain management clinic <br />permit may complete and submit to the Department a sworn application, <br />on a form provided by the Department, containing, at a minimum, the <br />following information: <br />a. The name and address of the pain management clinic; <br />b. The name and address of the owner of the pain management clinic; <br />c. The name and address of all physicians who will be prescribing controlled <br />substances at the pain management clinic; <br />d. Proof that the pain management clinic meets the definition of a "qualified <br />pain management clinic" which proof may consist of written verification or <br />confirmation from the State of Florida that the pain management clinic is <br />exempt from state registration pursuant to sections 458.3265(1)(a)2g or h <br />or 459.0137(1)(a)2g or h; and <br />e. A sworn statement certifying that the pain management clinic, and every <br />other clinic owned or operated by any person identified pursuant to <br />C.Vocuments and Settings9Icichewic.Local SettingstTemporary Internet FilesIOLK31Pain Clinic Revised Ordinance (July 101 I).rlocx <br />7 <br />