Fictitious Name Permit Application {FNP-001} | Pdf Fpdf Docx | California

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Fictitious Name Permit Application {FNP-001} | Pdf Fpdf Docx | California

Last updated: 5/2/2022

Fictitious Name Permit Application {FNP-001}

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OF CALIFORNIA MEDICAL BOARD Licensing Program 2005 Evergreen Street, Suite 1200 Sacramento, CA 95815-5401 Phone: (916) 263-2382 Fax: (916) 263-2487 www.mbc.ca.gov Protecting consumers by advancing high quality, safe medical care. Gavin Newsom, Governor, State of California | Business, Consumer Services and Housing Agency | Department of Consumer Affairs APPLICATION CHECKLIST FOR FICTITIOUS NAME PERMIT For all applications, did you: include a check for $50? indicate if you have additional practice locations? (Box 1) indicate the name for which you are applying? (Box 3) provide a translation or explanation of any foreign or non-standard English word to appear in the permit name? include ORIGINAL signatures? (Box 5 or Box 7) In addition, please be sure to complete the rest of the steps as listed below, depending on what kind of business is applying: If applying as a Corporation, did you: include a copy of your original endorsed Articles of Incorporation? include a copy of any endorsed Amended Articles of Incorporation? list all shareholders AND the percentage of the corporation they own? (Boxes 6a and 6b) fully fill out the signature block, leaving no blanks? (Box 7) If applying as a Partnership, did you: list your FEIN number? (Box 4) include a signature from each partner? fully fill out the signature block for each partner, leaving no blanks? (Box 5) If applying as a Partnership of Corporations, did you: complete all the steps for a regular Partnership? include a copy of your original endorsed Articles of Incorporation for each partner corporation? include a copy of any endorsed Amended Articles of Incorporation for each partner corporation? include a letter stating this is a sole shareholder professional medical corporation (letter must be signed by the shareholder) If applying as a Medical Group, did you: also fill out the application as either a CORPORATION or PARTNERSHIP? If applying as a Sole Proprietorship, did you: list your SSN number? (Box 4) fully fill out the signature block for the MD/DPM applying, leaving no blanks? (Box 5) American LegalNet, Inc. www.FormsWorkFlow.com I 217 217 I 217 217 217 217 217 Licensing Program 2005 Evergreen Street, Suite 1200 MEDICAL BOARD Sacramento, CA 95815-5401 Phone: (916) 263-2382 OF CALIFORNIA Fax: (916) 263-2487 Protecting consumers by advancing high quality, safe medical care. www.mbc.ca.gov Gavin Newsom, Governor, State of California | Business, Consumer Services and Housing Agency | Department of Consumer Affairs FICTITIOUS NAME PERMIT APPLICATION FOR OFFICE USE ONLY Fee Paid: Receipt No.: INSTRUCTIONS: Please print or type. ALL INCOMPLETE OR COPIED APPLICATIONS WILL BE RETURNED. For Individuals (Sole Proprietor) or Partnerships*: fill out items 1, 2, 3, 4, and 5 and mail with the $50 fee. For Corporations**: fill out items 1, 2, 3, 6a or 6b and 7 and mail with a copy of the endorsed Articles of Incorporation (articles that were originally filed with the Secretary of State and any amendments) and the $50 fee. * For Partnerships comprised of corporations, submit endorsed Articles of Incorporation for each corporation. ** In California you may only practice medicine as a corporation if you are a California Professional Medical Corporation (Business and Professions Code 2472402, Corporations Code 24713401.5). Fee: $50 (non-refundable) check, money order or cashier222s check Payable to: Medical Board of California Mail application to: Medical Board of California Licensing Program 2005 Evergreen Street, Suite 1200 Sacramento, CA 95815-3831 1. Practice Address (must be a physical address in California) Physician or Corporation Name Street Address (P.O. Boxes are not acceptable) City State Zip Code CA Telephone No. Additional Practice Locations: Yes No (List additional practice address(es) and telephone number(s) on a separate attachment) Mailing Address for the Fictitious Name Permit (if different than the practice address) Name Address City State Zip Code Person to be contacted regarding this application Name Telephone No. Address City State Zip Code 2. Business Type The applicant is applying as: (check only one) Individual (Sole Proprietor) Professional Medical Corporation* Partnership Professional Podiatry Corporation Medical Group *The corporation must be a California professional medical corporation incorporated under California Corporations Code 24713400 et. seq. Revised 01/2019 American LegalNet, Inc. www.FormsWorkFlow.com 3. Fictitious Name Choices Enter your fictitious name choices in order of preference. If the name is an acronym or includes abbreviations, foreign words or a name other than your own, please provide an explanation of its meaning. Names of current Fictitious Name Permits are on the Medical Board of California web site, www.mbc.ca.gov. Please review the site to determine if your name is available. Business and Professions Code 2472285 prohibits practicing under a fictitious name until the Board has issued a Fictitious Name Permit. 1. 2. 3. FOR INDIVIDUALS (SOLE PROPRIETORS) AND PARTNERSHIPS ONLY 4. If applying as an Individual (Sole Proprietor), enter your Social Security Number: If applying as a Partnership, enter your Federal Employer Identification Number (FEIN): 5. Owners Those with an ownership interest in the applicant must be listed and must sign below . Attach additional sheet(s) if necessary . The undersigned and each of the undersigned hereby certifies under penalty of perjury under the laws of the State of California that statements made on this Fictitious Name Permit Application, and all attachments thereto, are true and correct. Type/Print Name Medical License # Signature Date Type/Print Name Medical License # Signature Date Type/Print Name Medical License # Signature Date Type/Print Name Medical License # Signature Date Type/Print Name Medical License # Signature Date Type/Print Name Medical License # Signature Date Type/Print Name Medical License # Signature Date 2 American LegalNet, Inc. www.FormsWorkFlow.com FOR PROFESSIONAL CORPORATIONS ONLY 6. Shareholders A licensed physician and surgeon must own at least 51% of the outstanding shares of a professional medical corporation. The remaining 49% may be owned by licensed podiatrists, licensed psychologists, registered nurses, licensed optometrists, licensed marriage and family therapists, licensed clinical social workers, licensed physician assistants, licensed chiropractors, or licensed acupuncturists. The number of these licensed persons cannot exceed the number of physicians and cannot exceed a combined share total of 49%. A lay (unlicensed) person cannot own any shares in a professional medical corporation in California. 6a. If all shareholders are physicians , complete this section. If there are non - physician shareholders, proceed to 6b. Name (attach additional sheet(s) if necessary) Medical License No. Shareholder Yes No 6b. If ownership includes non - physicians , complete this section. Names of all shareholders (attach additional sheet(s) if necessary) License No. % of Shares Profession 7. Corporation Complete Name of Corporation Corporation # I certify at least 51% of said corporation222s shares are owned by a licensed physician and surgeon or podiatrist and as such make this declaration for and on behalf of said corporation. I have read the foregoing application and all attachments thereto and know the contents thereof, and the same are true of my own knowledge. I declare under penalty of perjury under the laws of the State of California that I am a licensed physician or podiatrist and have the legal authority to act on behalf of said corporation and that the information contained in this application and all attachments thereto is true and correct. Executed at , California, this day of , city day month year By: type/print name corporate title Signature: Visit the Medical Board of California web site at www.mbc.ca.govto download confirmation information. 3 American LegalNet, Inc. www.FormsWorkFlow.com The Information Practices Act, Section 1798.17 Civil Code, requires the following information to be provided when collecting information from individuals. Agency Name: Medical Board of California, L

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