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VPMS Exemption Form for Vermont Licensed Pharmacies

Vermont Prescription Monitoring Program
Division of Alcohol and Drug Abuse Programs
P.O. Box 70, 108 Cherry Street, Suite 2
Burlington, Vermont 05402-0070
Telephone: 802-922-7600
1. Pharmacy Information *This question is required.
2. I certify that this pharmacy currently: (select one) *This question is required.
Should this situation change, I understand that we need to contact the VPMS Program Manager ( and begin making reports of controlled substances dispensed to the Vermont Prescription Monitoring System which shall be no less than once every 24 hours or one (1) business day.  I understand that the exemption will need to be renewed annually during the exemption registration period which is January 1st through January 31st. 
This question requires a valid date format of MM/DD/YYYY.
This question requires a valid email address.
This question requires a valid email address.
6. Pharmacist Manager signature *This question is required.
Signature of