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Change Of Permit For Wholesaler (Instructions) 17A-63 - California
| Change Of Permit For Wholesaler (Instructions) Form. This is a California form and can be used in Board Of Pharmacy Statewide . |
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1625 N. Market Blvd, Suite N219, Sacramento, CA 95834 Phone (916) 574-7900 Fax (916) 574-8618 www.pharmacy.ca.gov California State Board of Pharmacy STATE AND CONSUMERS AFFAIRS AGENCY DEPARTMENT OF CONSUMER AFFAIRS GOVERNOR EDMUND G. BROWN JR. for WHOLESALER VETERINARY FOOD ANIMAL DRUG RETAILER HYPODERMIC NEEDLE AND SYRINGE PERMITS A request for a change of permit must be filed within 30 days when the following occurs: Change of corporate officers Change of tradestyle name Change of street name or number by the post office (not a change of location). Change of location CHANGE OF PERMIT Lost, stolen or damaged permits - Complete the Application for Reissue of a License (form 17A-28) and submit with the $30 processing fee, made payable to the "California Board of Pharmacy." The form may be found on the board's website at http://www.pharmacy.ca.gov/forms/duplicate_license_fee.pdf To be considered complete, all of the required forms must be submitted. Change of corporate officer 1. Completed Change of Permit form (17A-52). If the facility is owned by a partnership, corporation, or limited liability company, at least one individual authorized to act for and bind the entity must sign. If owned by a sole ownership, the owner must sign. 2. Processing fee of $100 made payable to the "California Board of Pharmacy." 3. Copy of Request for Live Scan Service Form verifying that your fingerprints have been scanned and all applicable fees have been paid for each new officer. (Please refer to fingerprint instructions on page 3.) 4. Completed Personal Background Affidavit (17A-37) form for each new corporate officer. 5. Attach one of the following: a. Statement of Information endorsed by the Secretary of State reflecting the corporate officer change, OR b. A copy of the board minutes reflecting the change of corporate officers. 6. If Indian owned, a copy of the constitution and by-laws establishing the tribal council that will be the governing entity of the pharmacy. 17A-63 (Rev 1/10) 1 American LegalNet, Inc. www.FormsWorkFlow.com Change of tradestyle name or corporation name 1. Completed Change of Permit form (17A-52). If the facility is owned by a partnership, corporation, or limited liability company, at least one individual authorized to act for and bind the entity must sign. If owned by a sole ownership, the owner must sign. 2. Processing fee of $35 made payable to the "California Board of Pharmacy." 3. For a tradestyle name change, attach a fictitious name statement from the county or copy of the board minutes ratifying the name change. 4. For a corporation name change provide a copy of the articles of incorporation listing the new name. Change of street name or number If this change is made by the post office. 1. Completed Change of Permit form (17A-52). If the facility is owned by a partnership, corporation, or limited liability company, at least one individual authorized to act for and bind the entity must sign. If owned by a sole ownership, the owner must sign. 2. Processing fee of $100 made payable to "California Board of Pharmacy." Change of location 1. Completed Change of Permit form (17A-52). If the facility is owned by a partnership, corporation, or limited liability company, at least one individual authorized to act for and bind the entity must sign. If owned by a sole ownership, the owner must sign. 2. Processing fee of $100 made payable to "California Board of Pharmacy." 3. Licensure verification from home state (if facility is located outside California) NOTE: For businesses located in California, the Board must approve all changes in location BEFORE the change occurs. 17A-63 (Rev 1/10) 2 American LegalNet, Inc. www.FormsWorkFlow.com Fingerprint Requirements California Residents The board will only accept Live Scan Service Forms from California residents. Complete a Live Scan Request form and take all 3 copies to a Live Scan site for fingerprint scanning. Please refer to the Instructions for completing a "Request for Live Scan Service" form. Live Scan sites are located throughout California. For more information about locating a Live Scan site near you, visit the Department of Justice website at http://ag.ca.gov/fingerprints/publications/contact.htm or the sources listed on the bottom of the instructions for completing a "Request for Live Scan Service" form. The lower portion of the Live Scan Request form must be completed by the Live Scan operator verifying that your prints have been scanned and all applicable fees have been paid. Attach the second copy of the form to your application and submit to the board. Non California Residents If an owner, partner, corporate officer, major shareholder or director reside out of state they must submit rolled fingerprints on cards provided by the board and include a separate fee of $51 ($32 California Department of Justice (DOJ) fee and $19 FBI fingerprint processing fee). (Live Scan processing fees are paid directly at the Live Scan site.) You may contact the board to request fingerprint cards at (916) 574-7943. You may also request cards on our website at www.pharmacy.ca.gov. Fingerprints submitted on cards should be taken by a person professionally trained in the rolling of prints. Fingerprint clearances from cards take approximately six weeks (live scan is faster). Poor quality prints may result in rejection and will substantially delay licensing as additional fingerprint cards will be required from you for processing. The board will only accept fingerprint cards from residents outside of California. 17A-63 (Rev 1/10) 3 American LegalNet, Inc. www.FormsWorkFlow.com
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