California > Statewide > Board Of Pharmacy
Change Of Permit For Wholesaler 17A-52 - California
| Change Of Permit For Wholesaler 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 ARNOLD SCHWARZENEGGER, GOVERNOR CHANGE OF PERMIT REQUEST Wholesaler, Veterinary Food Animal Drug Retailer, Hypodermic Needle and Syringe Permits (Print or type) Type of Change: Corporate officers Tradestyle name or corporation name change Change of street name or number made by postal service Current Permit Reads: Name of Corporation Address Name of Company City State Telephone No ( ) Zip Code Permit Number Change of responsible managing employee Change of branch manager Change of location New Permit should read: Name of Corporation Address Name of Company City State Telephone No ( ) Zip Code Permit Number List owners, partners, top 5 corporate officers, branch manager or responsible managing employee and indicate if this is a change, an addition or a deletion. List all individuals to be shown on permit, whether changed or not. Use additional sheets if needed. Name Title Name Title Name Title Name Title Name Title Residence Residence Residence Residence Residence Add City Delete Change title State Zip Code No change Add City Delete Change title State Zip Code No change Add City Delete Change title State Zip Code No change Add City Delete Change title State Zip Code No change Add City For Office Use Only Delete Change title State Zip Code No change Articles of Incorporation Fictitious name statement Minutes Statement of Information Approved _____________________ Denied _______________________ Date _________________________ Cashier # ____________________ Date ________________________ Amount ______________________ American LegalNet, Inc. www.FormsWorkflow.com 17A-52 (Rev 3/07) Page 1 of 2 List all persons who hold a Designated Representative* license: Name Name Name Name Designated Representative license No: Designated Representative license No: Designated Representative license No: Designated Representative license No: *Under California law, the name used to describe any individual who is in charge of any wholesale drug premises (in California or elsewhere) changed on January 1, 2006, from the former name, exemptee, to designated representative. Any material misrepresentation in the answer of any question is grounds for refusal or subsequent revocation of license, and a violation of the Penal Code of the State of California. I hereby certify that there have been no changes in officer(s), manager, or owner(s) that have not been reported to the Board of Pharmacy and that each such officer, manager or owner is the real party in interest with respect to his/her position and is not acting directly or indirectly as an agent, employee or representative of any other person not reported to the board. Under penalty of perjury, under the laws of the state of California, each person whose signature appears below, certifies and says: (1) He/she is the applicant, or one of the owners or managers of the applicant corporation, named in the foregoing application, duly authorized to make this application on its behalf; (2) that he/she has read the foregoing application and knows the contents thereof and that each and all statements therein made are true; (3) that no person other than the applicant or applicants has any direct or indirect interest in the applicant's or applicants' business to be conducted under the license(s) for which this application is made; (4) all supplemental statements are true and accurate. Signature(s) of Applicant: ______________________________________ Signature of Corporate officer, partner or owner ____________________________ Name (please print) _________________ Date ______________________________________ Signature of Corporate officer, partner or owner ____________________________ Name (please print) _________________ Date *Disclosure of your social security number is mandatory. Business and Professions Code section 30 and Public Law 94-455 (42 USCA 405(c)(2)(C) authorize collection of federal and employer identification number (FEIN for partnerships) or your social security number. Corporations are exempt. Your social security number will be used for tax enforcement purposes, for compliance with any judgement or order for family support in accordance with section 11350.6 of the Welfare and Institutions Code, or for verification of examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state. If you fail to disclose your social security number, 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. 17A-52 (Rev 3/07) Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com
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