California State Board of Pharmacy 1625 N. Market Blvd, N219 Sacramento, CA 95834 Phone: (916) 574-7900 Fax: (916) 574-8618 www.pharmacy.ca.gov Business, Consumer Services a nd Housing Agency Department of Consumer Affairs Gavin Newsom, Governor APPLICATION FOR CHANGE OF PHARMACIST-IN-CHARGE (PIC) The owner of a pharmacy and the PIC are required by California law to notify the California State Board of Pharmacy in writing within 30 days after the termination or change of the PIC. Failure to make this notification to the board may result in a citation and fine or other disciplinary action. INSTRUCTIONS: Submit a Change of PIC form and $100 Application Fee. Please make checks payable to the Board of Pharmacy (California government owned facilities are fee exempt). Important: LIST the license number for the facility and the PIC. Submit a Certification of Personnel form ONLYif the PIC is not licensed in California. Licensed Facility Location -Please Type or Print Name of License Facility Facility License Number Address of Facility 226 Street City State Zip Code Name of Person Authorized to Clarify Information provided on this form Telephone Number Email Address New PIC/Interim PIC (B&P Code 4113(e): Please identify if this is an interim PIC Yes No Name of New PIC Pharmacist License Number Residence Address 226 Street City State Zip Code Effective Start Date of New PIC PIC being REPLACED Name of Pharmacist Pharmacist License Number Residence Address 226 Street City State Zip Code End Date as PIC I certify under penalty of perjury under the laws of the State of California to the truth and accuracy of all statements, answers and representations made in the foregoing. (Please provide original signatures.) Signature of Corporate Officer, Print Name Title Date Partner, Owner or Member Signature of New PIC Date Signature of replaced PIC (If available) Date 17A-14 (4/2019) Board Use ONLY -Cashier # Date Amount American LegalNet, Inc. www.FormsWorkFlow.com