California > Statewide > Board Of Pharmacy
Application For Wholesaler License Partnership Owner 17A-68 - California
| Application For Wholesaler License Partnership Owner 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 Partnership Owner A. Applicant Information Please print or type ALL BLANKS MUST BE COMPLETED; IF NOT APPLICABLE, ENTER N/A Name of Applicant (Business Name): City Applicant telephone number: ( ) State Zip Code Address of Applicant: Number and Street Indicate whether this application is for: New Application Change of ownership of an existing nonresident wholesaler licensed with the 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 nonresident wholesaler. Name: 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 at this location. Name of designated representative-in-charge:* 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 For Office Use Only Processed By: Date: Approved __________________ Denied ____________________ Date ______________________ Cashier # ____________________ Date ________________________ Amount______________________ 17A-68 (Rev 1/12) Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com B. Partnership Information List the persons with the five largest ownership interests in the partnership below. Under the heading "License Held" list any state professional or vocational licenses held; e.g., pharmacist, physician, podiatrist, dentist, veterinarian, attorney or accountant, etc., and the license number (if applicable). Each person listed below must also: x x Complete and submit a Personal Background Affidavit (Form 17A-37). Submit one set of two fingerprints cards for both state and federal criminal background checks and a fingerprint processing fee of $51.00. If a partner is a partnership, limited liability company or corporation, the partner must: x x Complete and submit Business Background Affidavit (Form 17A-18). Specify an individual authorized to act for and bind the partnership who must 1. Complete and submit a Personal Background Certification (Form 17A-37). 2. One set of two Submit fingerprints for both state and federal criminal background checks a fingerprint processing fee of $51.00. Telephone number ( Address: Number and Street City State ) Zip Code Name: Title: License Held (type and state): License Held (type and state): License Held (type and state): Name of Authorized Agent: Name: Telephone number ( ) Zip Code Address: Number and Street City State Title: License Held (type and state): License Held (type and state): License Held (type and state): Name of Authorized Agent: Name: Telephone number ( ) Zip Code Address: Number and Street City State Title: License Held (type and state): License Held (type and state): License Held (type and state): Name of Authorized Agent: Name: Telephone number ( ) Zip Code Address: Number and Street City State Title: License Held (type and state): License Held (type and state): License Held (type and state): Name of Authorized Agent: American LegalNet, Inc. www.FormsWorkFlow.com 17A-68 (Rev 1/12) Page 2 of 5 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
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