California > Statewide > Board Of Pharmacy
Application For Nonresident Wholesaler License 17A-65 - California
| Application For Nonresident Wholesaler 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 NONRESIDENT WHOLESALER* LICENSE Corporation Owner A. Applicant Information Please print or type ALL BLANKS MUST BE COMPLETED; IF NOT APPLICABLE, ENTER N/A Name of Applicant (Business Name): Address of Applicant: Number and Street City Applicant telephone number: ( ) State Zip Code Indicate whether this application is for: Change of ownership of an existing nonresident wholesaler licensed with the New Application California Board of Pharmacy Effective date of transaction: If this is a change of ownership, indicate below the previous name, address and license number of the wholesaler. Name: California license number: Address: Number and Street City State Zip Identify a person located in California to act as an agent for service of process: Name of Agent for Service of Process: Agent's telephone number: ( Address of Agent: Number and Street City ) State Zip Code Who will be the designated representative-in-charge* of operations at this location: Name of Designated representative-in-charge*: California license Number Name, business address and telephone number of person authorized to clarify information provided on this application Name: Mailing Address: Street City Telephone: State Zip Processed By: Date: Approved __________________ Denied ____________________ Date ______________________ Cashier # ____________________ Date ________________________ Amount______________________ 17A-65 (Rev 1/12) Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com B. Executive Officers Information In the space below (attach additional pages if necessary) provide the requested information for each executive officer of the company. Under the heading "License Held" list any state professional or vocation licenses held; e.g., pharmacist, physician, podiatrist, dentist, veterinarian, attorney or accountant, etc., and the license number (if applicable). Each natural person listed below must also: x Complete and submit a Personal Background Affidavit (Form 17A-37). x Submit one set of two fingerprint cards to allow both state and federal criminal background checks and a fingerprint processing fee of $51. Name Address **Social security number/FEIN License Held (type and state): License Held (type and state): License Held (type and state): License Held (type and state): Name Address **Social security number/FEIN License Held (type and state): License Held (type and state): License Held (type and state): License Held (type and state): Name Address **Social security number/FEIN License Held (type and state): License Held (type and state): License Held (type and state): License Held (type and state): Name Address **Social security number/FEIN License Held (type and state): License Held (type and state): License Held (type and state): License Held (type and state): Name Address **Social security number/FEIN License Held (type and state): License Held (type and state): License Held (type and state): License Held (type and state): 17A-65 (Rev 1/12) Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com C. Background Information List all state(s) in which the applicant is or has been licensed as a wholesaler, pharmacy, manufacturer, or repackager (attach additional sheets if necessary): State License Number Issue Date Has any disciplinary or criminal action been taken against this license? Yes No If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. State License Number Issue Date Has any disciplinary or criminal action been taken against this license? Yes No If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. State License Number Issue Date Has any disciplinary or criminal action been taken against this license? Yes No If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. State License Number Issue Date Has any disciplinary or criminal action been taken against this license? Yes No If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. State License Number Issue Date Has any disciplinary or criminal action been taken against this license? Yes No If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. State License Number Issue Date Has any disciplinary or criminal action been taken against this license? Yes No If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. State License Number Issue Date Has any disciplinary or criminal action been taken against this license? Yes No If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. State License Number Issue Date Has any disciplinary or criminal action been taken against this license? Yes No If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. State License Number Issue Date Has any disciplinary or criminal action been taken against this license? Yes No If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. State License Number Issue Date Has any disciplinary or criminal action been taken against this license? Yes No If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. State License Number Issue Date Has any disciplinary or criminal action been taken against this license? Yes No If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. State License Number Issue Date Has any disciplinary or criminal action been taken against this license? Yes No If yes, you must attach a written explanation givi
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