17A-65 (Rev /2018) Page 1 of 7 NONRESIDENT WHOLESALER LICENSE APPLICATIONI.Applicant Business Information Please print or typeName of Nonresident Wholesaler as it will appear on the License 226 may include DBA (Cannot exceed 65 characters includingspaces): Legal Name of Nonresident Wholesaler Business: Location of Business: Number and Street City State Zip Code Email Address: Telephone Number of Applicant Business: ( ) II.Application Type: Check all that apply and attach appropriate fee(s). New Nonresident Wholesaler License Anticipated Opening Date: Change of Ownership Anticipated Change of Ownership Date: Change of Physical Location Anticipated Move Date: Temporary License Request 226 Additional fee required III.Change of Ownership or LocationName on Current Nonresident Wholesaler License: License Number and Expiration Date: Address: Effective Date of Change of Ownership/Move: Has the regulatory agency in your home state been notified of the change in ownership? YES NO If yes, is the home state license issued to the new ownership?YES NO Has the regulatory agency in your home state been notified of the change in location? YES NO If yes, is the home state license issued to the new location?YES NO IV.Type of Ownership Individual Partnership Corporation Publicly Traded Limited Liability Company Trust Government (not publicly traded) FEIN # (Federal Employer ID #)Contact person for this application. The board will ONLY discuss the status of this application with the personidentified as the contact person and any person who has signed the application as an officer, partner, member,and/or owner of the applicant business. An authorized owner may designate additional individuals to receiveinformation on this pending application by submitting the Authorization to Release Applicant Information form. Name: Telephone: Mailing Address: Number and StreetCityState Zip Code Email Address: For Office Use Only Date Processed: By: Date Sent to 2LR: By: Date 2LR reviewed: By: Date Issued: By: Post Issuance: By Cashier #: Date: Amount: California State Board of PharmacyBUSINESS, CONSUMER SERVICES AND HOUSING AGENCY 1625 N. Market Blvd, Suite N219, Sacramento, CA 95834 DEPARTMENT OF CONSUMER AFFAIRS Phone (916) 574-7900 Fax (916) 574-8618 GOVERNOR EDMUND G. BROWN JR. www.pharmacy.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com 17A-65 (Rev /2018) Page 2 of 7 VII.Applicant Business Operations1.Will this wholesaler SOLELY operate as a Reverse Distributor? YES NO If yes, is this for the purposes of the California Drug Take-Back Program? YES NOA reverse distributor participating in the California Drug Take-Back Program is required to have a licensed desi g nated representative-reverse distributor or licensed pharmacistas the desi g nated representative-in-char g e. 2.Is there a Third-Party Logistics Provider operation at the same address as the wholesaler? YES NO If yes, list name and license number.Is the wholesaler and third-part y lo g istic provider under common ownership?YES NO 3.Is this business a virtual manufacturer registered with the FDA? YES NO Is this business a manufacturer registered with the FDA? YES NO If yes, does the business own the NDA and/or ANDA? YES NO This nonresident wholesaler will ship or restock to: (Check all that apply) PharmaciesHospitalsPrescribersPrescriber groupsExempt Hospitals without pharmacistsClinicsOther licensed healthcare practitionersA Licensed EMSADDSNon-Licensed OutletsSpecify: Other: Type of products this nonresident wholesaler will handle: (Check all that apply)Dangerous DrugsControlled substancesDangerous devicesBiologics/BiosimilarsVeterinary drugsMedical gasesDialysis suppliesOver-the-counter medicationsAcupuncture Needles VIII.Person or Agency located in California that will act as an agent for service of process.Name: Telephone: Mailing Address: Number and Street City State Zip Code Email Address: I.Designated Representative-in-Charge (DRIC)List the designated representative, designated representative-reverse distributor, or pharmacist to serve as the DRIC of this wholesaler business. If the wholesaler acts only as a reverse distributor participating in the California Drug Take-Back Program, a designated representative-reverse distributor or licensed pharmacist shall serve as the DRIC. The DRIC serves as a supervisor or manager who is responsible for ensuring the wholesaler222s compliance with all state and federal laws and regulations pertaining to the wholesaler operations. A DRIC must hold a current California designated representative or designated representative-reverse distributor license. A pharmacist fulfilling these duties shall not be required to obtain a license as a designated representative or designated representative-reverse distributor. The nonresident wholesaler shall comply with California Business and Professions Code section 4161. Name of Designated Representative-in-Charge: License Type and No. Residence Address of Designated Representative-in-Charge: City State Zip Code Original Signature of Designated Representative-in-Charge: Date II.Ownership InformationCalifornia Business and Professions Code section 4035 specifies 223person" includes firm, association, partnership, corporation, limited liability company, state governmental agency, trust, or political subdivision. The application shall provide information to identify the ownership of the applicant business. This may include a parent company as well as each officer, partner and member (as appropriate) for the applicant business. Please provide an American LegalNet, Inc. www.FormsWorkFlow.com 17A-65 (Rev /2018) Page 3 of 7 organizational chart that clearly documents the applicant business222 ownership structure, including percentages owned by all parties. Complete and submit a Business Background Affidavit (17A-18) for an entity listed on page 3 signed by its authorized agent. Any natural person listed on page 4 needs to complete and submit a Personal Background Affidavit (17A-37). The board may require additional documentation to confirm or substantiate the reported ownership structure at any time during the application process. Entities: If the applicant business is owned by an entity (not a natural person), identify each parent entity that has beneficial interest and has management and control of the applicant business, and identify its authorized agent. The authorized agent shall be an officer, partner, member, owner, or trustee of the parent business who is authorized to bind the business. Name of Partnership (attach additional sheets if necessary): % of ownership Telephone Number ( ) Address: Number and Street City State Zip Code Name of Authorized Agent: Authorized Agent telephone number: Name of Partner 1:% of ownership Telephone Number ( ) Address: Number and Street City State Zip Code Name of Authorized Agent: Authorized Agent telephone number: Name of Partner 2:% of ownership Telephone Number ( ) Address: Number and Street City State Zip Code Name of Authorized Agent: Authorized Agent Telephone Number: Name of Corporation: % of ownership Telephone Number ( ) Address: Number and Street City State Zip Code Name of Authorized Agent: Authorized Agent Telephone Number: Name of Limited Liability Company:% of ownership Telephone Number ( ) Address: Number and Street City State Zip Code Name of Authorized Agent: Authorized Agent Telephone Number: Name of Government Agency or Trust: % of ownership Telephone Number ( ) Address: Number and Street City State Zip Code Name of Authorized Agent: Authorized Agent Telephone Number: American LegalNet, Inc. www.FormsWorkFlow.com 17A-65 (Rev /2018) Page 4 of 7 Natural Person(s): Provide the name(s) of each owner, partner, member, stockholder, trustee, or administrator (government owned) who is a natural person of the applicant business. If there are no natural person(s) under the applicant business, list the owner(s), partner(s), member(s), stockholder(s), trustee(s), or administrator (government owned) who are natural persons for the parent business as listed in the Entities section. Natural persons identified shall be authorized to act for and bind the applicant business. Name: Position Ti