California > Statewide > Board Of Pharmacy
Application For Wholesaler License Sole Owner 17A-13 - California
| Application For Wholesaler License Sole Owner Form. This is a California form and can be used in Board Of Pharmacy Statewide . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
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 Sole Owner A. APPLICANT INFORMATION The business owner must complete a Personal Background Affidavit (form 17A-37) and one set of two fingerprints cards along with a fingerprint processing fee of $51.00. License verification must be provided for each license granted outside of California (form 17M-17). Please print or type ALL BLANKS MUST BE COMPLETED; IF NOT APPLICABLE, ENTER N/A Name of Applicant (Business Name): Applicant telephone number: ( Address of Applicant: Number and Street City ) State Zip Code Business Owner's Name: Last First Middle Date of birth: (Month, Day, Year) Previous name(s) include maiden name, also known as (AKA's), "aliases": *Social Security number: Indicate whether this application is for: New Wholesaler Change of ownership of an existing non resident wholesaler licensed with the California Board of Pharmacy Effective date of transaction: If this is a change of ownership, indicate below the name, address and license number of the existing California licensee. Business 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: Address of Agent: City Agent's telephone number: ( ) State Zip Code Number and Street Who will be the designated representative-in-charge** at this location. Name of designated representative-in-charge**: License Number: For Office Use Only Processed By: Date: Approved __________________ Denied ____________________ Date ______________________ Cashier # ____________________ Date ________________________ Amount______________________ 17A-13 (1/12) Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com B. Background Information List every state 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 giving full details. Failure to provide an explanation will delay the processing of your application. 17A-13 (1/12) Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com 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
|
|||||||
