Before a pharmacist may dispense or distribute at a setting that does not hold a pharmacy permit under Regulation .01A(1) of this chapter, the pharmacist shall submit to the Board a request for approval signed by the pharmacist, which includes: The name and license number of the pharmacist; The scope of services to be provided by the pharmacist at the nonpharmacy setting; The name and address of the nonpharmacy setting where the pharmacist intends to dispense or distribute; and A statement indicating the pharmacist's criminal history, if any. If the pharmacist intends to provide drug therapy management services in a licensed physician's office under Regulation .01A(1)(a) of this chapter, in addition to the requirements of §A of this regulation, the pharmacist shall provide: The name and license number of the licensed physician; and Proof of an approved physician-pharmacist agreement with the licensed physician.