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Change Of Permit Pharmacy Hospital Clinic Non-Resident Pharmacy Licensed Correctional Facility (Instructions) 17M-70 - California

Change Of Permit Pharmacy Hospital Clinic Non-Resident Pharmacy Licensed Correctional Facility (Instructions) 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., N219, Sacramento, CA 95834 Phone (916) 574-7900 Fax (916) 574-8617 www.pharmacy.ca.gov BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY DEPARTMENT OF CONSUMER AFFAIRS GOVERNOR EDMUND G. BROWN JR. CHANGE OF PERMIT APPLICATION INSTRUCTIONS Pharmacy, Nonresident Pharmacy, Hospital Pharmacy, Clinic, Correctional Facility, Sterile Compounding A Change of Permit Application must be submitted to the board within 30 days when one of the following changes occurs: Address Change: Includes change of street name or number made by the United States Postal Service, government entity, suite number, etc. (Does NOT include a physical change of location.) Change of Tradestyle Name or Corporate Name (Does not a change of ownership.) Change of Officer(s), Partner(s), Member(s), or Owner(s) Change of Administrator and/or Professional/Medical Director (Clinic and Exempt Hospital) Change to the Warden (Correctional Facility) Transfer an Assignment of Beneficial Interest of 10% to 49% All of the required forms identified in the application instructions must be submitted with the application. If the facility is owned by a corporation, at least one officer must sign; if owned by a partnership, one partner must sign; if individual ownership, the majority owner must sign; or a limited liability company, one member must sign. Allow the board 30 days for processing the application. A deficiency letter will be mailed to you if the application is incomplete. The board may require additional documentation to confirm or substantiate the ownership structure reported at any time during the application process. Visit the board's Web site to view pharmacy laws and regulations at http://www.pharmacy.ca.gov/laws_regs/index.shtml. CHANGE OF PERMIT APPLICATION (17A-12): Complete a Change of Permit application for each license affected by the change. If making changes to multiple licenses submit an application and the application processing fee for EACH license. This includes submitting a separate application and the application processing fee for the sterile compounding license attached to the primary pharmacy license. The Change of Permit application processing fee and required documentation will depend on the type of change that occurs. Please read section A and B below to determine the appropriate application fee to submit of $35 or $100 as well as the required documentation to include with the application. Please note: If submitting multiple changes to a current license that fall under both A and B below, the application fee is $100 for each license. A. APPLICATION FEE $35 AND REQUIRED DOCUMENTATION: Include a check or money order for $35 made payable to the Board of Pharmacy to notify the board of the following changes in section 1 and/or 2 below. The application fee is non-refundable. If making changes to multiple licenses submit a separate application and fee for EACH license. (Note: Government owned facilities are fee exempt) 1. ddress Change: This ONLY includes a change of street name or number made by the United A States Postal Service, government entity, suite number, etc. This does NOT include a physical change of location. A physical change of location requires a new license application. Required documentation, submit a, b, and/or c: a) A copy of the notice received from the United States Postal Service or Government entity reporting the change. b) Lease Agreement ­ Submit a copy of the lease agreement showing the new address. c) Board minutes ratifying the address change. Page 1 of 4 17M-70 (rev 2/2016) 2. Change of Tradestyle Name or Corporate Name: This does NOT include a change of ownership. A change of ownership requires a new license application. Required documentation, submit a, b, and/or c, as appropriate: a) Fictitious name statement filed with the county. b) Copy of the Articles of Incorporation/Organization or Partnership Agreement listing the new name. c) Copy of the board minutes ratifying the name change. B. APPLICATION FEE $100 AND REQUIRED DOCUMENTATION: Include a check or money order for $100 made payable to the Board of Pharmacy to notify the board of each of the following changes identified in section 1 and/or 2 below. The application fee is non-refundable. If making changes to multiple licenses, submit an application and fee for EACH license. (Note: Government owned facilities are fee exempt.) 1. Add and/or Remove Officer(s), Partner(s), Member(s), Owner(s), Administrator, Professional/Medical Director, and/or Warden: Below is a list of required documents to include with the application. California and Nonresident Pharmacy/Sterile Compounding Pharmacy/Hospital Certificate of Personnel (17A-11): Submit a completed form for each NEW officer, partner, member, and/or owner with original signature. Individual Personal Affidavit (17A-27): Submit a completed form for each NEW officer, partner, member, and/or owner with original signature. Individual Financial Affidavit (17A-26): Submit a completed form for each NEW officer, partner, member, and/or owner as well as a copy of the bank statement for the bank account listed on the Individual Financial Affidavit, if applicable. Documentation verifying Officer, Partner, Member, or Owner Change: Submit one or more of the following: a) Statement of Information. Copy of the filing with the Secretary of State reflecting the officer change and bearing the Secretary of State stamp. b) A copy of the board minutes reflecting the change. c) Letter of resignation or memo formally documenting the change. Indian Owned, if applicable: A copy of the constitution and bylaws establishing the tribal council that will be the governing entity of the licensed facility. Fingerprints: Any new person being added to the license. If a person is currently associated with a current license and has fingerprints on file with the California State Board of Pharmacy, new fingerprints may not be required. Please reference page 4 of the application for instructions on submitting fingerprints. Clinic or Exempt Hospital (100 beds or less) The following is required when submitting a change of Administrator and/or Professional/Medical Director. Certificate of Personnel (17A-11): Submit a completed form for the NEW Administrator, and/or Professional/Medical Director. Documentation if the new Administrator and/or Professional/Medical Director is also an Officer, Partner, Member, or Owner Change: Submit one or more of the following: a
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