California > Statewide > Board Of Pharmacy
Community Pharmacy Permit Application 17A-4 - California
| Community Pharmacy 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. COMMUNITY PHARMACY PERMIT APPLICATION Please print or type Name of Pharmacy: ALL BLANKS MUST BE COMPLETED; IF NOT APPLICABLE, ENTER N/A Pharmacy Telephone Number ( ) Street and Number City State Zip Code Address of Pharmacy: Indicate type of pharmacy practice: (check all that apply) Retail Mail Order Home Health Care Skilled Nursing Facility Nuclear Board & Care Indicate whether this application is for: New pharmacy Change of Location of an existing pharmacy Change of Ownership of an existing pharmacy If this is a change of ownership or change of location, indicate previous name, address and license number of pharmacy. Date of proposed change of ownership or location _______________________________ Please indicate type of ownership: Corporation ___ Not-for-profit Will this pharmacy dispense replacement contact lenses to patients? Yes Individual Partnership Limited Liability Government owned No By your affirmative answer above, your pharmacy name will be provided to the California Medical Board and you will be in compliance with section 4124 of the California Business and Professions Code. CONTINUE ON REVERSE FOR OFFICE USE ONLY STAFF REVIEW Articles of Incorporation Financial Aff Partnership agreement Stock certificate Seller's certificate Whlse agreement By-laws Lease CASHIER LOG Cashier # Date _________________ _________________ Approved ________________ Denied Date ________________ ________________ Amount of fee _________________ 17A-4 Page 1 of 3 Premises leased/rented Premises owned If the premises are leased/rented, are they leased/rented from a person who is licensed in California to prescribe? Yes No Address City/State/Zip Telephone number ( Name of lessee or renter Address City/State/Zip ) Name of lessor/rentor or owner Telephone number ( ) Monthly Rental $ Expiration date of lease: A copy of the lease agreement must accompany this application. Anticipated first day of business: Name and address of pharmacist-in-charge Pharmacist license number Name and telephone number of contact person to clarify information provided on this application ( ) e-mail address PLEASE READ CAREFULLY This application must be approved by the California State Board of Pharmacy before a pharmacy 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, CA 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. 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. CONTINUE ON NEXT PAGE 17A-4 Page 2 of 3 Certification of Applicant ALL OWNERS AND OFFICERS MUST SIGN BELOW 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 direct or indirect interest in the applicant(s) business to be conducted under the license(s) for which this application is made; (4) all supplemental statements are true and accurate; and (5) the transfer application may be withdrawn by either the applicant or the licensee with no resulting liability to the Board of Pharmacy. Signature of corporate officer, partner or owner Name (please print) Title Date Signature of corporate officer, partner or owner Name (please print) Title Date Signature of corporate officer, partner or owner Name (please print) Title Date Signature of corporate officer, partner or owner Name (please print) Title Date Signature of corporate officer, partner or owner Name (please print) Title Date 17A-4 (Rev. 1/12) 17A-4 Page 3 of 3
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