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Change Of Permit Pharmacy Hospital Clinic Non-Resident Pharmacy Licensed Correctional Facility 17A-12 - California
| Change Of Permit Pharmacy Hospital Clinic Non-Resident Pharmacy Licensed Correctional Facility 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 STATE AND CONSUMER SERVICES AGENCY DEPARTMENT OF CONSUMER AFFAIRS ARNOLD SCHWARZENEGGER, GOVERNOR CHANGE OF PERMIT REQUEST (Pharmacy, Hospital Pharmacy, Clinic, Licensed Correctional Facility, Exempt Hospital, Non-Resident Pharmacy) TYPE OF CHANGE CHECK ALL THAT APPLY ¨ ¨ ¨ Corporate Officer(s) Medical Director Transfer of 10%-49% of stock ¨ ¨ ¨ Address (not change of location) Tradestyle Name Corporation Name Please print or type Name of permit holder Telephone Number ( ) Zip Code Address of permit holder Number and Street City State Name of business Permit number Business phone number ( ) Zip Code Address of business Number and Street City State A. Corporate Officers LIST CHANGES ONLY Under "Licensed as" list any state professional or vocational licenses held; e.g., pharmacist, physician, podiatrist, dentist or veterinarian, etc., and the license number. Non-profit organizations must list the names and titles of persons holding corporate positions. For Office Use Only Name of CEO Licensed as License number Residence address City State Zip Code ¨ Certs ¨ FP ¨ FPC For Office Use Only Name of President Licensed as License number Residence address City State Zip Code ¨ Certs ¨ FP ¨ FPC For Office Use Only Name of Secretary Licensed as License number Residence address City State Zip Code ¨ Certs ¨ FP ¨ FPC Continue on Reverse FOR OFFICE USE ONLY Articles of Inc Fict. Name Stmt Minutes ¨ ¨ ¨ Date application completed Date changes made on system Staff initials _________________ _________________ _________________ Cashier # ____________________________ Date _____________________________ Amt of fee ____________________________ American LegalNet, Inc. www.FormsWorkflow.com 1 Name of Treasurer Residence address City Licensed as License number For Office Use Only State Zip Code ¨ Certs ¨ FP ¨ FPC For Office Use Only Name of Medical Director Licensed as License number Residence address City State Zip Code ¨ Certs ¨ FP ¨ FPC B. Shareholders To whom issued COMPLETE ONLY IF THERE IS A STOCK TRANSFER Residence address & telephone no. Licensed as, license no. and state(s) % of Shares Date Issued List all persons who own 10% or more of stock (use additional sheet if necessary). Please read carefully The information will be used to determine qualifications for registration under the California Pharmacy Law. The official responsible for information maintenance is the Executive Officer, telephone (916)574-7900, 1625 N. Market Blvd, N219, Sacramento, California 95834. The information may be transferred to another governmental agency such as a law enforcement agency if necessary for it to perform its duties. Each individual has the right to review the files or records maintained on them by our agency, unless the records are identified as confidential information and exempted by Section 1798.3 of the Civil Code. 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 owner or an officer of the applicant corporation named in the foregoing application, duly authorized to make this application on its behalf and is at least 18 years of age; (2) he/she has read the foregoing application and knows the contents thereof and that each and all statements therein made are true; (3) all supplemental statements are true and accurate; (4) the transfer application may be withdrawn by either the applicant or the licensee with no resulting liability to the Board of Pharmacy. SIGNATURE __________________________________________________ Signature of Corporate Officer or Owner ________________________________ _________________ Name (please print) Date __________________________________________________ Signature of Corporate Officer or Owner ________________________________ _________________ Name (please print) Date 17A-12 (Rev. 3/99) 2 American LegalNet, Inc. www.FormsWorkflow.com
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