Указ Губернатора Орловской области от 30.10.2012 № 441

|         | подтверждающего факт уплаты   | Дата _____________________________                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     |
|         | государственной пошлины за    | В размере __________________________                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   |
|         | предоставление лицензии, либо |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         | иные сведения, подтверждающие |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         | факт уплаты указанной         |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         | государственной пошлины       |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|—————————|———————————————————————————————|————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|  12.2.  | Выполняемые работы,           | 2. Аптечные организации:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               |
|         | оказываемые услуги, которые   |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         | лицензиат прекращает          | 2.1. Аптека готовых лекарственных форм                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 |
|         | исполнять при осуществлении   | ___________________________________                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    |
|         | фармацевтической деятельности |                                                                                                                                                                                                                                                                                               (адрес места осуществления фармацевтической деятельности)                                                                                                                                                                                                                                                                                                |
|         | в сфере обращения             |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         | лекарственных средств для     | 2.2. Аптека производственная                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           |
|         | медицинского применения.      | ___________________________________                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    |
|         |                               |                                                                                                                                                                                                                                                                                               (адрес места осуществления фармацевтической деятельности)                                                                                                                                                                                                                                                                                                |
|         | Адрес(а) мест осуществления   |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         | лицензируемого вида           | 2.3. Аптека производственная с правом изготовления асептических лекарственных препаратов                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               |
|         | деятельности                  | ___________________________________                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    |
|         |                               |                                                                                                                                                                                                                                                                                               (адрес места осуществления фармацевтической деятельности)                                                                                                                                                                                                                                                                                                |
|         |                               |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         |                               | 2.4. Аптечный пункт                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    |
|         |                               |                                                                                                                                                                                                                                                                            ___________________________________ (адрес места осуществления лицензируемого вида деятельности)                                                                                                                                                                                                                                                                            |
|         |                               |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         |                               | 2.5. Аптечный киоск                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    |
|         |                               | ___________________________________                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    |
|         |                               |                                                                                                                                                                                                                                                                                              (адрес места осуществления лицензируемого вида деятельности)                                                                                                                                                                                                                                                                                              |
|         |                               |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         |                               | __* хранение лекарственных средств для медицинского применения;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         |                               | __* хранение лекарственных препаратов для медицинского применения;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     |
|         |                               | __* перевозка лекарственных препаратов для медицинского применения;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    |
|         |                               | __* перевозка лекарственных средств для медицинского применения;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       |
|         |                               | __* розничная торговля лекарственными препаратами для медицинского применения;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
|         |                               | __* отпуск лекарственных препаратов для медицинского применения;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       |
|         |                               | __* изготовление лекарственных препаратов для медицинского применения.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 |
|         |                               |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         |                               |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         |                               | 3. Структурные подразделения медицинских организаций:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  |
|         |                               |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         |                               | 3.1. Аптека готовых лекарственных форм                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 |
|         |                               |                                                                                                                                                                                                                                                                            ___________________________________ (адрес места осуществления лицензируемого вида деятельности)                                                                                                                                                                                                                                                                            |
|         |                               |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         |                               | 3.2. Аптека производственная                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           |
|         |                               | ___________________________________                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    |
|         |                               |                                                                                                                                                                                                                                                                                               (адрес места осуществления фармацевтической деятельности)                                                                                                                                                                                                                                                                                                |
|         |                               |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         |                               | 3.3. Аптека производственная с правом изготовления асептических лекарственных препаратов                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               |
|         |                               | ___________________________________                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    |
|         |                               |                                                                                                                                                                                                                                                                                               (адрес места осуществления фармацевтической деятельности)                                                                                                                                                                                                                                                                                                |
|         |                               |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         |                               | 3.4. Аптечный пункт                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    |
|         |                               |                                                                                                                                                                                                                                                                            ___________________________________ (адрес места осуществления лицензируемого вида деятельности)                                                                                                                                                                                                                                                                            |
|         |                               |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         |                               | __* хранение лекарственных средств для медицинского применения;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         |                               | __* хранение лекарственных препаратов для медицинского применения;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     |
|         |                               | __* перевозка лекарственных препаратов для медицинского применения;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    |
|         |                               | __* перевозка лекарственных средств для медицинского применения;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       |
|         |                               | __* розничная торговля лекарственными препаратами для медицинского применения;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
|         |                               | __* отпуск лекарственных препаратов для медицинского применения;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       |
|         |                               | __* изготовление лекарственных препаратов для медицинского применения.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 |
|         |                               |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         |                               | 4. Обособленные подразделения медицинских организаций, расположенных в сельских поселениях, в которых отсутствуют аптечные организации:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                |
|         |                               |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         |                               | 4.1. Центр (отделение) общей врачебной (семейной) практики                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             |
|         |                               |                                                                                                                                                                                                                                                                            ___________________________________ (адрес места осуществления лицензируемого вида деятельности)                                                                                                                                                                                                                                                                            |
|         |                               |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         |                               | 4.2. Амбулатория                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       |
|         |                               |                                                                                                                                                                                                                                                                            ___________________________________ (адрес места осуществления лицензируемого вида деятельности)                                                                                                                                                                                                                                                                            |
|         |                               |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         |                               | 4.3. Фельдшерский пункт                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                |
|         |                               |                                                                                                                                                                                                                                                                            ___________________________________ (адрес места осуществления лицензируемого вида деятельности)                                                                                                                                                                                                                                                                            |
|         |                               |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         |                               | 4.4. Фельдшерско-акушерский пункт                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      |
|         |                               |                                                                                                                                                                                                                                                                            ___________________________________ (адрес места осуществления лицензируемого вида деятельности)                                                                                                                                                                                                                                                                            |
|         |                               |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         |                               | __* хранение лекарственных препаратов для медицинского применения;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     |
|         |                               | __* перевозка лекарственных препаратов для медицинского применения;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    |
|         |                               | __* розничная торговля лекарственными препаратами для медицинского применения;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
|         |                               | __* отпуск лекарственных препаратов для медицинского применения.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       |
|         |                               |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         |                               | 5. Индивидуальные предприниматели                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      |
|         |                               |                                                                                                                                                                                                                                                                            ___________________________________ (адрес места осуществления лицензируемого вида деятельности)                                                                                                                                                                                                                                                                            |
|         |                               | __* хранение лекарственных средств для медицинского применения;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         |                               | __* хранение лекарственных препаратов для медицинского применения;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     |
|         |                               | __* перевозка лекарственных препаратов для медицинского применения;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    |
|         |                               | __* перевозка лекарственных средств для медицинского применения;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       |
|         |                               | __* розничная торговля лекарственными препаратами для медицинского применения;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
|         |                               | __* отпуск лекарственных препаратов для медицинского применения;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       |
|         |                               | __* изготовление лекарственных препаратов для медицинского применения.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 |
|         |                               | 6. Иные организации, осуществляющие обращение лекарственных средств                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    |
|         |                               |                                                                                                                                                                                                                                                                            ___________________________________ (адрес места осуществления лицензируемого вида деятельности)                                                                                                                                                                                                                                                                            |
|         |                               | __* хранение лекарственных средств для медицинского применения;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         |                               | __* хранение лекарственных препаратов для медицинского применения;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     |
|         |                               | __* перевозка лекарственных препаратов для медицинского применения;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    |
|         |                               | __* перевозка лекарственных средств для медицинского применения;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       |
|         |                               | __* розничная торговля лекарственными препаратами для медицинского применения;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
|         |                               | __* отпуск лекарственных препаратов для медицинского применения;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       |
|         |                               | __* изготовление лекарственных препаратов для медицинского применения                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  |
|—————————|———————————————————————————————|————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|  12.3.  | Дата фактического прекращения |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         | лицензиатом выполнения,       |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         | указанных в лицензии работ,   |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         | услуг                         |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|—————————|———————————————————————————————|————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|   13.   | __* истечением срока действия лицензии (лицензий), не содержащей (не содержащих) перечня выполняемых работ, оказываемых услуг, составляющих лицензируемый вид деятельности                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             |
|         |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|—————————|————————————————————————————————————————————————|———————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|  13.1.  | Реквизиты документа, подтверждающего факт      | N платежного                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          |
|         | уплаты государственной пошлины за              | поручения __________________                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          |
|         | предоставление лицензии, либо иные сведения,   | Дата ______________                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   |
|         | подтверждающие факт уплаты указанной           | В размере __________                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  |
|         | государственной пошлины                        |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       |
|—————————|———————————————————————————————|————————————————||——————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|  13.2.  | Выполняемые работы,           |   (Сведения о   |                                                                                                                                                                                                                                                                                                    (Новые сведения о лицензиате)                                                                                                                                                                                                                                                                                                     |
|         | оказываемые услуги в составе  |   лицензиате)   | 2. Аптечные организации:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             |
|         | фармацевтической деятельности |                 |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      |
|         | в сфере обращения             |                 | 2.1. Аптека готовых лекарственных форм                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               |
|         | лекарственных средств для     |                 | ______________________________________________                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       |
|         | медицинского применения.      |                 |                                                                                                                                                                                                                                                                                      (адрес места осуществления фармацевтической деятельности)                                                                                                                                                                                                                                                                                       |
|         |                               |                 |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      |
|         | Адрес(а) мест осуществления   |                 | 2.2. Аптека производственная                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
|         | лицензируемого вида           |                 | ______________________________________________                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       |
|         | деятельности                  |                 |                                                                                                                                                                                                                                                                                      (адрес места осуществления фармацевтической деятельности)                                                                                                                                                                                                                                                                                       |
|         |                               |                 |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      |
|         |                               |                 | 2.3. Аптека производственная с правом изготовления асептических лекарственных препаратов                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             |
|         |                               |                 | ______________________________________________                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       |