Permit application.

(1) The department shall adopt rules to establish the form and content of the application to obtain a permit and to renew a permit listed under this part.

(2) An applicant must be at least 18 years of age or be managed, controlled, or overseen, directly or indirectly, by a natural person who is at least 18 years of age.

(3) An application for a permit must be filed with the department and must include all of the following information:

(a) The trade or business name of the applicant, including current and former fictitious names, which may not be identical to a name used by an unrelated entity permitted in this state to dispense or distribute medical gas.

(b) The name or names of the owner and operator of the applicant, if not the same person or entity. The application must also include:

1. If the applicant is an individual, the applicant’s name, business address, and date of birth.

2. If the applicant is a sole proprietorship, the business address of the sole proprietor and the name and federal employer identification number of the business entity.

3. If the applicant is a partnership, the name, business address, date of birth of each partner, the name of the partnership, and the partnership’s federal employer identification number.

4. If the applicant is a limited liability company, the name, business address, and title of each company officer, the name of the limited liability company and federal employer identification number, and the name of the state in which the limited liability company was organized.

5. If the applicant is a corporation, the name, business address, and title of each corporate officer and director, the corporate names, the state of incorporation, the federal employer identification number, and, if applicable, the name and business address of the parent company.

(c) A list of disciplinary actions pertinent to wholesale distributors, manufacturers, and retailers of prescription drugs or controlled substances by a state or federal agency against the applicant seeking to distribute into this state and any such disciplinary actions against such applicant’s principals, owners, directors, or officers.

(d) A complete disclosure of all of the applicant’s past felony convictions.

(e) An address and description of each facility and warehouse, including all locations used for medical gas storage or wholesale distribution including a description of each facility’s security system.

(4) An applicant shall attest in writing that the information contained in its application is complete and accurate.

(5) An applicant must submit a reasonable fee, to be determined by the department, in order to obtain a permit.

(a) The fee for a medical gas wholesale distributor permit may not be less than $200 or more than $300 annually.

(b) The fee for a medical gas manufacturer permit may not be less than $400 or more than $500 annually.

(c) The fee for a medical oxygen retail establishment permit may not be less than $200 or more than $300 annually.

(6) Upon approval of the application by the department and payment of the required fee, the department shall issue a permit to the applicant pursuant to the rules adopted under this part.