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. APPLICATION FOR NONRESIDENT WHOLESALER* LICENSE Close 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): Address of Applicant: Number and Street City Applicant telephone number: ( ) State Zip Code Indicate whether this application is for: New Application Change of ownership of an existing nonresident wholesaler licensed with the 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: California license number: Address: 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 * Note: 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 will refer to such a business as a nonresident wholesaler throughout this application. 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 will refer to such an individual as a designated representative throughout this application. Processed By: Date: Approved __________________ Denied ____________________ Date ______________________ Cashier # ____________________ Date ________________________ Amount______________________ 17A-62 (Rev 1/12) Page 1 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Name, business address and telephone number of person authorized to clarify information provided on this application Name: Address: Street City Telephone: State Zip B. Top 5 Owners In the space below provide the requested information for the top five owners. Under the heading "License Held" list any state professional or vocational 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: x x 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 $51. For each owner that is a partnership, limited liability company or corporation, the member must: x x Complete and submit Business Background Affidavit (Form 17A-18). Specify an individual authorized to act for and bind the limited liability company, such as a member, manager, or principal/executive officer (e.g., president/CEO, chairperson). This individual must also: x x Complete and submit a Personal Background Affidavit (Form 17A-37). Submit fingerprints for both state and federal criminal background checks and the fingerprint processing fee of $51. Telephone number ( Address: Number and Street City State ) Zip Code Name: Title: License Held (type and state): License Held (type and state): License Held (type and state): Name of Authorized Agent: Name: Telephone number ( ) Zip Code Address: Number and Street City State Title: License Held (type and state): License Held (type and state): License Held (type and state): Name of Authorized Agent: 17A-62 (Rev 1/12) Page 2 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Name: Telephone number ( ) Zip Code Address: Number and Street City State Title: License Held (type and state): License Held (type and state): License Held (type and state): Name of Authorized Agent: Name: Telephone number ( ) Zip Code Address: Number and Street City State Title: License Held (type and state): License Held (type and state): License Held (type and state): Name of Authorized Agent: Name: Telephone number ( ) Zip Code Address: Number and Street City State Title: License Held (type and state): License Held (type and state): License Held (type and state): Name of Authorized Agent: C. 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 vocational licenses held; e.g., pharmacist, physician, podiatrist, dentist, veterinarian, attorney, accountant, etc., and the license number (if applicable). Name Address License Held (type and state): License Held (type and state): License Held (type and state): *Social security number/FEIN License Held (type and state): Name Address *Social security number/FEIN License Held (type and state): License Held (type and state): License Held (type and state): License Held (type and state): 17A-62 (Rev 1/12) Page 3 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Name Address *Social security number/FEIN License Held (type and state): License Held (type and state): License Held (type and state): License Held (type and state): Name Address *Social security number/FEIN License Held (type and state): License Held (type and state): License Held (type and state): License Held (type and state): Name Address *Social security number/FEIN License Held (type and state): License Held (type and state): License Held (type and state): License Held (type and state): D. 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 No If yes, you must attach a written explanation giving full details. Failure to provide an explanation will delay the processing of your application. State License Number Issue Date Has any disciplinary or criminal action been