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Requirements For Filing A Community Pharmacy Application 17M-45 - California
| Requirements For Filing A Community Pharmacy Application Form. This is a California form and can be used in Board Of Pharmacy Statewide . |
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1625 N. Market Blvd, N219, Sacramento, CA 95834 Phone (916) 574-7900 Fax (916) 574-8617 www.pharmacy.ca.gov California State Board of Pharmacy STATE AND CONSUMER SERVICES AGENCY DEPARTMENT OF CONSUMER AFFAIRS GOVERNOR EDMUND G. BROWN JR. REQUIREMENTS FOR FILING A COMMUNITY PHARMACY APPLICATION IMPORTANT: Please follow these instructions completely. Failure to submit the necessary items will delay the processing of your application. If the number of forms provided is not sufficient, please make photocopies. You will be notified of any major deficiencies in your application. Please allow approximately 60 days from the time your application packet is complete before calling the Board of Pharmacy. Any forms that have been previously submitted with another application will not be pulled from the file. You must complete and submit all of the requested information. If you would like notification that the board has received your application, please submit a stamped postcard addressed to yourself. SUMMARY OF CHECKLIST Section A Requirements for all applicants except government owned, Indian tribe owned, or change of location. Note: All pharmacy change of ownership applications will be considered for temporary permits. Whenever a change of ownership occurs, either a temporary permit will be pursued or operation must stop. In addition to the regular items required for this application, a $250.00 temporary permit fee must also be submitted. Forms required for an applicant who is filing as an individual owner Forms required for an applicant whose ownership is a partnership Forms required for an applicant who is filing as a corporation Forms required for an applicant who is filing as a limited liability company Requirements for state, city or county owned pharmacy and city or county ed jail pharmacies Requirements for Native American tribe owned pharmacy Requirements for non-Native American owned but operating on tribal lands Section B Section C Section D Section E Section F own Section G Section H Section I Requirements for change of location only (no ownership change) American LegalNet, Inc. www.FormsWorkFlow.com CHECKLIST FOR FILING A COMMUNITY PHARMACY APPLICATION Section A [] [] All Applicants 1. Application (17A-4) and the non-refundable processing fee of $400. 2. Ownership form a. b. Corporation OR Limited Liability Company (17A-33 ) OR Partnership or Individual (17A-34) [] 3. Financial Affidavit in Support of Application (17A-2) (NOTE - Not needed for a change of location or non-profit organization) AND [] [] [] 4. Approved wholesale credit application or wholesale agreement (NOTE - Not needed for a non-profit organization) 5. Copy of the lease agreement 6. Seller's Certification for a Pharmacy (17A-8) (If applicable) This is only required for an application for a change of ownership and it must be submitted by the prospective owner(s). Section B Individual Owner who is not incorporated In addition to items listed in Section A, the following must be submitted: [] [] [] [] 1. Certification of Personnel (17A-11) 2. Individual Personal Affidavit (17A-27) 3. Individual Financial Affidavit (17A-26) 4. Copy of Request for Live Scan Service Form verifying that your fingerprints have been scanned and all applicable fees have been paid. Please refer to fingerprint instructions on page 7. 5. Certification of Personnel (17A-11) for the pharmacist-in-charge [] -2American LegalNet, Inc. www.FormsWorkFlow.com Section C Partnership In addition to items listed in Section A, the following must be submitted: [] 1. Each partner must submit: · · · · Certification of Personnel (form 17A-11) Individual Personal Affidavit (17A-27) Individual Financial Affidavit (form 17A-26) Copy of Request for Live Scan Service Form verifying that your fingerprints have been scanned and all applicable fees have been paid. Please refer to fingerprint instructions on page 7. [] [] 2. Certification of Personnel (17A-11) for the pharmacist-in-charge 3. Signed Partnership Agreement If the partners are a corporation or a limited liability company (LLC), then complete and provide the same documents required of corporations (see section D). Section D Corporations In addition to items listed in Section A, the following must be submitted: The first line corporation over the pharmacy needs to complete a form 17A-33. Each remaining parent corporation, over the first line corporation, needs to complete a form 17A-33A. For Profit For the named corporation on the application, or person(s) who owns an interest in, the corporation named on the application the following is required: [] 1. Each corporate officer, major shareholder, and director must submit: · · · · Certification of Personnel (17A-11) Individual Personal Affidavit (17A-27) Individual Financial Affidavit (form 17A-26) Copy of Request for Live Scan Service Form verifying that your fingerprints have been scanned and all applicable fees have been paid. Please refer to fingerprint instructions on page 7. [] [] 2. Certification of Personnel (17A-11 for the pharmacist-in-charge) 3. Articles of Incorporation endorsed by the Secretary of State. -3American LegalNet, Inc. www.FormsWorkFlow.com [] 4. Statement a. Statement of Information endorsed by the Secretary of State. An endorsed copy must be requested from the Secretary of State. OR b. Statement by Foreign Corporation endorsed by the California Secretary of State. This is only required if the named corporation on the application is incorporated outside of California. [] 5. By-laws Non-Profit For the named corporation on the application, or person(s) who owns an interest in, the corporation named on the application, the following is required: [] [] [] [] 1. Statement of Information endorsed by the Secretary of State. 2. By-laws 3. Articles of Incorporation endorsed by the Secretary of State. 4. Each corporate officer, shareholder, and director must submit: · [] Certification of Personnel (17A-11) 5. Certification of Personnel (17A-11) for the pharmacist-in-charge Publicly Traded Corporation [] [] 1. A copy of the corporation's 10K filing with the Securities Exchange Commission. 2. A list of the five largest shareholders who own 5% or more of stock which requires a filing with the Securities Exchange Commission. If the shareholder is an individual, include name, title and professional license (if applicable). Also, identify if the shareholder is a bank, trust company or financial institution to which a license is issued in a fidu
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