California State Board of Pharmacy STATE AND CONSUMER SERVICES AGENCY 1625 N. Market Blvd, Suite N219, Sacramento, CA 95834 Phone (916) 574-7900 Fax (916) 574-8618 www.pharmacy.ca.gov DEPARTMENT OF CONSUMER AFFAIRS ARNOLD SCHWARZENEGGER, GOVERNOR APPLICATION FOR NONRESIDENT WHOLESALER* LICENSE Corporation Owner A. Applicant Information Please print or type ALL BLANKS MUST BE COMPLETED; IF NOT APPLICABLE, ENTER N/A Name of Applicant (Business Name): Applicant telephone number: ( Address of Applicant: ) City Number and Street State Zip Code Indicate whether this application is for: Change of ownership of an existing nonresident wholesaler licensed with the New Application California Board of Pharmacy Effective date of transaction: If this is a change of ownership, indicate below the previous name, address and license number of the wholesaler. Name: Address: California license number: Number and Street City State Zip Identify a person located in California to act as an agent for service of process: Name of Agent for Service of Process: Agent’s telephone number: ( Address of Agent: Number and Street ) City State Zip Code Who will be the designated representative-in-charge* of operations at this location: Name of Designated representative-in-charge*: California license Number Name, business address and telephone number of person authorized to clarify information provided on this application Name: Mailing Address: Telephone: Street City State Zip Processed By: Approved __________________ Cashier # ____________________ Date: Denied ____________________ Date ________________________ Date ______________________ Amount______________________ 17A-65 (Rev 1/05) Page 1 of 5 American LegalNet, Inc. www.FormsWorkflow.com B. Executive Officers Information In the space below (attach additional pages if necessary) provide the requested information for each executive officer of the company. Under the heading “License Held” list any state professional or vocation licenses held; e.g., pharmacist, physician, podiatrist, dentist, veterinarian, attorney or accountant, etc., and the license number (if applicable). Each natural person listed below must also: • Complete and submit a Personal Background Affidavit (Form 17A-37). • Submit one set of two fingerprint cards to allow both state and federal criminal background checks and a fingerprint processing fee of $66. Name Address License Held (type and state): **Social security number/FEIN License Held (type and state): License Held (type and state): License Held (type and state): Name Address License Held (type and state): **Social security number/FEIN License Held (type and state): License Held (type and state): License Held (type and state): Name Address License Held (type and state): **Social security number/FEIN License Held (type and state): License Held (type and state): License Held (type and state): Name Address License Held (type and state): **Social security number/FEIN License Held (type and state): License Held (type and state): License Held (type and state): Name Address License Held (type and state): 17A-65 (Rev 1/05) **Social security number/FEIN License Held (type and state): License Held (type and state): Page 2 of 5 License Held (type and state): American LegalNet, Inc. www.FormsWorkflow.com C. Background Information List all state(s) in which the applicant is or has been licensed as a wholesaler, pharmacy, manufacturer, or repackager (attach additional sheets if necessary): State License Number Issue Date Has any disciplinary or criminal action been taken against this license? Yes State License Number Issue Date License Number Issue Date License Number Issue Date License Number Issue Date License Number Issue Date License Number Issue Date License Number Issue Date License Number Issue Date License Number Issue Date License Number Issue Date License Number Issue Date If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. No If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. No If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. No If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. No If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. No If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. Has any disciplinary or criminal action been taken against this license? Yes 17A-65 (Rev 1/05) No Has any disciplinary or criminal action been taken against this license? Yes State If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. Has any disciplinary or criminal action been taken against this license? Yes State No Has any disciplinary or criminal action been taken against this license? Yes State If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. Has any disciplinary or criminal action been taken against this license? Yes State No Has any disciplinary or criminal action been taken against this license? Yes State If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. Has any disciplinary or criminal action been taken against this license? Yes State No Has any disciplinary or criminal action been taken against this license? Yes State If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. Has any disciplinary or criminal action been taken against this license? Yes State No Has any disciplinary or criminal action been taken against this license? Yes State If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. Has any disciplinary or criminal action been taken against this license? Yes State No No Page 3 of 5 If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. American LegalNet, Inc. www.FormsWorkflow.com State License Number Issue Date Has any disciplinary or criminal action been taken against this license? Yes State License Number Issue Date License Number Issue Date License Number Issue Date License Number Issue Date License Number Issue Date License Number Issue Date License Number Issue Date License Number Issue Date License Number Issue Date License Number Issue Date License Number Issue Date License Number Issue Date No If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. No If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. No If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. No If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. No If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. No If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. Has any disciplinary or criminal action been taken against this license? Yes 17A-65 (Rev 1/05) If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. Has any disciplinary or criminal action been taken against this license? Yes State No Has any disciplinary or criminal action been taken against this license? Yes State If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. Has any disciplinary or criminal action been taken against this license? Yes State No Has any disciplinary or criminal action been taken against this license? Yes State If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. Has any disciplinary or criminal action been taken against this license? Yes State No Has any disciplinary or criminal action been taken against this license? Yes State If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. Has any disciplinary or criminal action been taken against this license? Yes State No Has any disciplinary or criminal action been taken against this license? Yes State If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. Has any disciplinary or criminal action been taken against this license? Yes State No Has any disciplinary or criminal action been taken against this license? Yes State If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. Has any disciplinary or criminal action been taken against this license? Yes State No No Page 4 of 5 If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. American LegalNet, Inc. www.FormsWorkflow.com *Under California law, the name used to describe any business, located outside California that ships drugs into California at wholesale, will change on January 1, 2006, from the former name, out of state distributor, to nonresident wholesaler. For conventional use, the board refers to such a business as a nonresident wholesaler. Similarly under California law, the name used to describe any individual who is in charge of any wholesale drug premises (in California or elsewhere) will change on January 1, 2006, from the former name, exemptee, to designated representative. For conventional use, the board refers to such an individual as a designated representative. **Disclosure of a social security number (or federal employer identification number ["FEIN"], if a partnership) is mandatory. Section 30 of the Business and Professions Code and Public Law 94-455 (42 USCA 405[c][2][C]) authorize collection of a social security number. A social security number or FEIN will be used exclusively for tax enforcement purposes, for purposes of compliance with any judgment or order for family support in accordance with section 11350.6 of the Welfare and Institutions Code and Section 17520 of the Family Code, or for verification of licensure or examination status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state. Failure to disclose a social security number or a FEIN, this application for initial or renewal license will not be processed AND will be reported to the Franchise Tax Board, which may assess a $100 penalty. D. Certification of Applicant – PLEASE READ CAREFULLY AND SIGN BELOW This application must be approved by the California State Board of Pharmacy before a nonresident wholesaler license will be issued and the applicant can do business in California. If changes are made during the application process, the applicant may need to submit a new application with appropriate fees. Fees applied to this application are not transferable and are not refundable. All items of information in this application are mandatory. Failure to provide any of the requested information will result in the application being rejected as incomplete. Any material misrepresentation in the answer of any question is grounds for refusal or subsequent revocation of license, and a violation of the Penal Code of California. The information will be used to determine qualifications for licensure under the California Pharmacy Law. The official 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 him/her by the Board of Pharmacy, unless the records are identified as confidential information and exempted by section 1798.38 of the Civil Code. Signature Block Under penalty of perjury, under the laws of the State of California, I certify and affirm that: (1) I am a person authorized to act for and bind the applicant and I am at least 18 years of age; (2) I have read the foregoing application and know the contents thereof and each and every statement made therein is true and correct; (3) I understand that falsification of any information I this application may constitute grounds for denial or subsequent revocation of the license; (4) no person other than the applicant [or applicants] has any direct or indirect interest in the applicant’s [or applicants’] business to be conducted under the license for which this application is made; and (5) all supplemental statements filed with this application are true, complete and accurate. Signature of Person Authorized to Submit Application 17A-65 (Rev 1/05) Name (please print) Page 5 of 5 Title Date American LegalNet, Inc. www.FormsWorkflow.com