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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 .
 Fillable pdf Last Modified 3/17/2016
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California State Board of Pharmacy . CHANGE OF PERMIT APPLICATION INSTRUCTIONS Pharmacy, Nonresident Pharmacy Hospital Pharmacy, Sterile Compounding Pharmacy Clinic, Correctional Facility CHANGE OF PERMIT APPLICATION AND APPLICATION FEE (17A-12): EACH Please note: EACH A. $35 Application Processing Fee B. $100 Application Processing Fee American LegalNet, Inc. www.FormsWorkFlow.com CHECKLIST FOR FILING A CHANGE OF PERMIT APPLICATION ADDRESS CHANGE (not a physical change of location) This does NOT include a physical change of location. A physical change of location requires a new license application. CHANGE OF TRADESTYLE NAME OR CORPORATE NAME A change of ownership requires a new license application. CHANGE OF OFFICER, PARTNER, MEMBER, OWNER, ADMINISTRATOR, DIRECTOR, WARDEN California and Nonresident Pharmacy/Sterile Compounding/Hospital/Exempt Hospital (100 beds or less) Clinic and Hospital American LegalNet, Inc. www.FormsWorkFlow.com Correctional Facility TRANSFER AN ASSIGNEMENT OF BENEFICIAL INTEREST (ownership, stock, etc.) NOT NOTE: Change of Ownership: A transfer of beneficial interest in the facility licensed by the board, in a single transaction or in a series of transactions, to any person or entity, which transfer results in the transferee's holding 50% or more of the beneficial interest in the licensed facility shall complete the appropriate licensing application and submit all required documents as instructed in a change of ownership application. All approved change of ownership applications result in a new license number being issued. California and Nonresident Pharmacy/Sterile Compounding/Hospital Clinic or Exempt Hospital (100 beds or less) American LegalNet, Inc. www.FormsWorkFlow.com FINGERPRINTS (Not required if the license is nonprofit or owned by the state, city or county) Who is required to complete the Live Scan or fingerprint cards? Any new person being added to the license as listed below. If a person is currently associated with an active license and has fingerprints already on file with the California State Board of Pharmacy, new fingerprints may not be required. Officer: Partner: Limited Liability Company: Owner: Administrator: Director: Fingerprint Instructions: ONE A. California Resident: Type of License/Certification/Permit or Working Title: Date of Birth: Social Security Number (SSN) or Individual Taxpayer Identification Number (ITIN): Level of Service: B. Non-California Resident: American LegalNet, Inc. www.FormsWorkFlow.com
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