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(2) Application. Any pain management clinic requesting issuance of a pain <br />management clinic permit shall complete and submit to the Department a <br />sworn application, on a form provided by the Department, containing, at a <br />minimum, the following information: <br />a. The name and address of the pain management clinic; <br />b. The name and address of each owner of the pain management clinic <br />(including, if the owner is a business entity such as a corporation, limited <br />liability company, etc, the name and address of each officer, manager or <br />managing member, general partner or other comparable person <br />authorized by state law to manage the affairs of the business entity), each <br />person who will be managing or supervising the activities of the pain <br />management clinic, and each person who will be prescribing or <br />administering controlled substances, and each person who will be <br />acquiring possessing processing transferring selling distributing or <br />dispensing marijuana at the pain management clinic; <br />c. The name and address of the person who has been designated as the <br />responsible physician or osteopathic physician for the pain management <br />clinic, pursuant to sections 458.3265(1)(c) or 459.0137(1)(c), Florida <br />Statutes, if applicable; <br />d. The name and address of the person or entity which owns the real <br />property upon which the pain management clinic will be operated; <br />e. Proof that the applicant is currently registered as a pain management clinic <br />with the Florida Department of Health, pursuant to sections 458.3265 or <br />459.0137, Florida Statutes or registered as a Medical Mariivana Treatment <br />Center, pursuant to Article X, Section 29 of the Florida Constitution; <br />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. 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 />72 <br />F'Uttnrsglfi�dvlGFl.PR1L1Rewlmiw@Ad�cesiOld'nmrellPen QmicM/r�cnlM �va�adoa 7 <br />