Community Pharmacy Permit Application {17A-4}

17A-4 - COMMUNITY PHARMACY LICENSE APPLICATION. This form is used to apply for licensure to operate a pharmacy in California through the State Board of Pharmacy. This comprehensive form collects detailed information about the applicant business, including ownership structure, pharmacy services, physical location, and proposed pharmacist-in-charge (PIC). It is required for new pharmacy licenses, as well as changes in ownership or location. Applicants must disclose management personnel, ownership interests, vendor relationships, and any disciplinary history, along with supporting documentation such as agreements and affidavits. The application also includes certification and compliance statements confirming adherence to California pharmacy laws. A license must be approved and issued before the pharmacy may legally operate in the state. \ The information requested on this application is used to determine qualifications for licensure of a pharmacy under California Pharmacy Law. Failure to provide the requested information may result in the application being considered incomplete. www.FormsWorkflow.com