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Application For A Sterile Compounding Pharmacy License 17A-48 - California
| Application For A Sterile Compounding Pharmacy License Form. This is a California form and can be used in Board Of Pharmacy Statewide . |
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California State Board of Pharmacy 1625 N. Market Blvd, Suite N219, Sacramento, CA 95834 Phone (916) 574-7900 Fax (916) 574-8618 www.pharmacy.ca.gov STATE AND CONSUMERS AFFAIRS AGENCY DEPARTMENT OF CONSUMER AFFAIRS GOVERNOR EDMUND G. BROWN JR. APPLICATION FOR A STERILE COMPOUNDING PHARMACY LICENSE Please print or type ALL BLANKS MUST BE COMPLETED; IF NOT APPLICABLE, ENTER N/A Name of Pharmacy: Pharmacy Telephone Number: Pharmacy License Number Sterile Compounding Telephone Number: (if different) Address of Pharmacy: Street and Number City State Zip Code Name of pharmacist-in-charge of licensed pharmacy: Pharmacist license number Residence address: Street and Number City State Zip Code Indicate whether this application is for: New Licensed Sterile Compounding License Change of Location of Licensed Sterile Compounding pharmacy Change of Ownership of Licensed Sterile Compounding pharmacy If this is a change of ownership or change of location, indicate previous name, address and license number of compounding pharmacy. Name: Address: License Number: Please indicate type of ownership: Individual Partnership Corporation Not-for-profit corporation Government owned I certify that the policies and procedures of the sterile compounding are consistent with California Code of Regulations Title 16, section 1735 et seq and 1751 et seq (A copy of the pharmacy's proposed policies and procedures for sterile compounding must accompany the application.) Signature of Pharmacist-in-Charge CONTINUE ON REVERSE Name (please print) Date FOR OFFICE USE ONLY STAFF REVIEW CASHIER LOG ___________ ___________ ___________ ___________ Approved ________________ Denied Date ________________ ________________ Cashier # Date _________________ _________________ Referred for inspection: ______________ Inspection Completed: ______________ Amount of fee _________________ 17A-48 (1/12) -1- American LegalNet, Inc. www.FormsWorkFlow.com Ownership Information A license to compound injectable sterile drug products may only be issued to the owner of a licensed pharmacy at the licensed location. If a Sole Ownership: Name of Sole Owner *Social Security Number Telephone Number Address number and street City State Zip Code If a Partnership: (attach additional sheet if needed) Name of Partner *FEIN Number Telephone Number Address number and street City State Zip Code Name of Partner *FEIN Number Telephone Number Address number and street City State Zip Code If a Corporation: (attach additional sheet if needed) Name of Corporation (If applicable) Telephone Number Address number and street City State Zip Code Print below the name, title, address and license number of all the pharmacy owners. This includes the individual owner, all partners, corporate officers. Under the heading "Licensed as" list any state professional or vocational licenses held; e.g., pharmacist, physician, podiatrist, dentist or veterinarian etc., and license number. Non-profit organizations must list the names and titles of persons holding corporate positions. Attach additional sheets if necessary. Title Name Residence Address Social Security Number Licensed as and license number *Disclosure of your social security number (or federal employer identification number ("FEIN"), if you are a partnership) is mandatory. Section 30 of the Business and Professions Code and Public Law 94-455 (42 USCA 405(c)(2)(C)) authorize collection of your social security number. Your social security number or FEIN will be used exclusively for tax enforcement purposes or compliance with any judgment or order for family support in accordance with section 17520 of the Family Code. If you fail to disclose your social security number or your FEIN, your application for initial or renewal license will not be processed AND you may be reported to the Franchise Tax Board, which may assess a $100 penalty against you. NOTICE: Effective July 1, 2012, the State Board of Equalization and the Franchise Tax Board may share individual taxpayer information with the board. You are obligated to pay your state tax obligation. This application may be denied or your license may be suspended if the state tax obligation is not paid. *Federal Employer Identification Number 17A-48 (1/12) -2American LegalNet, Inc. www.FormsWorkFlow.com PLEASE READ CAREFULLY This application must be approved by the California State Board of Pharmacy before a Sterile Compounding License will be issued. If changes are made during the application process, you may need to submit a new application with the appropriate fees. Any application not completed within 60 days after you have been notified by the board of deficiencies in your file, may be deemed to have been abandoned, and you may be required to file a new application and meet all the requirements which are in effect at the time of application. Fees applied to this application are not transferable and are not refundable. Any material misrepresentation in the answer of any question is grounds for refusal or subsequent revocation of a license, and is a violation of the Penal Code of California. All items of information requested in this application are mandatory. Failure to provide any of the requested information will result in the application being rejected as incomplete. The information will be used to determine qualifications for licensure under California Pharmacy Law. The officer responsible for information maintenance is the Executive Officer, (916) 445-5014, 400 R Street, Suite 4070, Sacramento, California 95814. The information may be transferred to another governmental agency (such as a law enforcement agency) if necessary for it to perform its duties. Each individual has the right to review the files or records maintained on him/her by the Board of Pharmacy, unless the records are identified as confidential information and exempted from disclosure by the California Information Practices Act. (Civil Code ยง1798, et seq.) Signature Block Under penalty of perjury, under the laws of the State of California, I certify and affirm that: (1) I am a person authorized to act for and bind the applicant and I am at least 18 years of age; (2) I have read the foregoing application and know the contents thereof and each and every statement made therein is true; (3) I understand that falsification of any information I this application may constitute grounds for denial or subsequent revocation of the license; (4) no person other than the applicant [or applicants] has any direct or ind
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