California > Statewide > Board Of Pharmacy
Clinic Permit Application 17A-42 - California
| Clinic Permit Application 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 GOVERNOR EDMUND G. BROWN JR. CLINIC PERMIT APPLICATION Please print or type All blanks must be completed. If not applicable enter N/A Name of Clinic: Clinic telephone number: Address of Clinic: Number and street City State Zip Code Type of Clinic: Free Surgical Indicate whether this application is for: New Clinic Change of Location Change of Ownership Multi-Specialty Ambulatory Surgical Community Non Profit Profit Other If change of ownership or change of location, indicate previous name, address and license number of clinic: Type of ownership: Individual Date of last inspection by the Department of Health Services: Partnership Limited Liability Company Are you Medicare Certified? If yes, attach a copy of your current medicare certificate. Yes Anticipated first day of business: No Corporation Government Mail all correspondence to the following address below. If correspondence should be mailed to the clinic please insert "Same as Clinic." Name and telephone number of contact person to clarify information provided on this application. e-mail address ( ) Continue on reverse For Office Use Only Staff Review Articles of Inc or Org Partner Agreement Seller's Cert DHS lic/waiver Policy & Proc Medicare cert Approval_________________ Denied__________________ Date____________________ Cashier Cashiering #___________________ Date_________________________ Amount of Fee_________________ Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Ownership Information Name of Sole Owner (If applicable) *Social Security Number Telephone Number Address number and street City State Zip Code Name of Partner (If applicable) *FEIN Number Telephone Number Address number and street City State Zip Code Name of Partner (If applicable) *FEIN Number Telephone Number Address number and street City State Zip Code Name of Corporation/Limited Liability Company (If applicable) Telephone Number Address number and street City State Zip Code Print below the name, title, address and license number of all the clinic owners. This includes the individual owner, all partners, corporate officers, members, managers. Under the heading "Licensed as" list any state professional or vocational licenses held; e.g., pharmacist, physician, podiatrist, dentist or veterinarian etc., and license number. Non-profit organizations must list the names and titles of persons holding corporate positions. Attach additional sheet if necessary. Title Name Residence Address Licensed as and license number *Disclosure of your U.S. social security account number, or federal employer identification number (FEIN) if you are a partnership, is mandatory. Section 30 of the Business and Professions Code, section 17520 of the Family Code, and Public Law 94-455 (42 USC 405(c)(2)(C)) authorize collection of your social security account number. Your social security account number or FEIN will be used exclusively for tax enforcement purposes, or for purposes of compliance with any judgment or order for child or family support in accordance with section 17520 of the Family Law Code. If you fail to disclose your social security account number or your FEIN, your application will not be processed and you may be reported to the Franchise Tax Board, which may assess a $100 penalty against you. NOTICE: Effective July 1, 2012, the State Board of Equalization and the Franchise Tax Board may share individual taxpayer information with the board. You are obligated to pay your state tax obligation. This application may be denied or your license may be suspended if the state tax obligation is not paid. FEDERAL EMPLOYEE ID NUMBER (FEIN): Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Name of Professional Director: License Number Residence Address City State Zip Code Name of Administrator: License Number Residence Address City State Zip Code Name of Consulting pharmacist: License Number Residence Address City State Zip Code I certify that the policies and procedures of the clinic's drug distribution service are consistent with the promotion and protection of health and safety of the public regarding inventories, security, training, protocol development, recordkeeping, packaging, labeling dispensing, and patient consultation. Signature of Consulting Pharmacist Name (please print) Date PLEASE READ CAREFULLY This application must be approved by the California State Board of Pharmacy before a clinic permit will be issued. If changes are made during the application process, you may need to submit a new application with the appropriate fees. Any application not completed within 60 days of receipt may be deemed withdrawn by the Board of Pharmacy. Fees applied to this application are not transferable and are not refundable. Any material misrepresentation in the answer of any question is grounds for refusal or subsequent revocation of a license, and is a violation of the Penal Code of California. All items of information requested in this application are mandatory. Failure to provide any of the requested information will result in the application being rejected as incomplete. The information will be used to determine qualifications for licensure under California Pharmacy Law. The officer responsible for information maintenance is the Executive Officer, (916) 574-7900, 1625 N. Market Blvd., Suite 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 him/her by the Board of Pharmacy, unless the records are identified as confidential information and exempted by Section 1798.3 of the Civil Code. Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Under penalty of perjury, under the laws of the State of California, each person whose signature appears below, certifies and says that: (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) no person other than the applicant or applicants has any
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