1 of 6 17M- (rev /2018) NONRESIDENT WHOLESALER LICENSE APPLICATION INSTRUCTIONS A nonresident wholesaler license is required for any business or person who acts as a wholesale merchant, broker, jobber, customs broker, reverse distributor, agent, or a nonresident wholesaler, who sells for resale, or negotiates for distribution, or takes possession of, any drug or device doing business with California. (Business and Professions Code section 4043) IMPORTANT: Please follow these instructions completely. Failure to submit the necessary items will delay the processing of your application. If the number of forms included in this application is not sufficient, please make copies. Please allow approximately 60 days from the date your application is submitted before checking on the status. The contact person designated on the application will be advised if additional information is necessary. A checklist is provided with the application to assist you. The board encourages the applicant to refer to the checklist to assist with the application process and to submit all supporting documentation along with the application. It is not uncommon for the board to request additional documentation to confirm or substantiate information contained in the application. SUMMARY OF CHECKLIST Section A Nonresident Wholesaler Application and Processing Fee (All Applicants) Section B Change of Ownership / Change of Location Section C Nonresident Wholesaler Ownership Documents (All Applicants) - Please refer to the respective ownership section (C1-C7) in the application instructions to identify the appropriate ownership documents to submit with the application. C1 - Individual Owner C2 - Partnership C3 226 Corporation (Not Publicly Traded) C4 - Publicly Traded Corporation C5 - Limited Liability Company C6 - Trust C7 - Government Owned (state, city or county) Section D Bond Requirements (All applicants) Section E Fingerprint Requirements (All Applicants) Effective July 1, 2018, Business and Professions Code section 4201(a) specifies, 223the application shall state the information as to each person beneficially interested or any person with management or control over the license224. With the addition of management or control over the license, officers/owners of nonprofit corporations will be required to have his/her fingerprints completed through the Department of Justice and Federal Bureau of Investigation. California State Board of Pharmacy BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY 1625 N. Market Blvd., Suite N-219 DEPARTMENT OF CONSUMER AFFAIRS Sacramento, CA 95834 GOVERNOR EDMUND G. BROWN JR. Phone (916) 574-7900 Fax (916) 574-8617 www.pharmacy.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com 2 of 6 17M-4 (rev 8/2018) CHECKLIST FOR FILING A NONRESIDENT WHOLESALER APPLICATION Use the checklist below to assist in completing the nonresident wholesaler application and to provide the required supporting documents for the applicant business222 ownership structure. Section A Nonresident Wholesaler Application (All Applicants) All applicants are required to complete and submit the following: Nonresident Wholesaler Application (17A-65): Complete the entire application and submit with originalsignatures.Do Not Leave Blanks: If an item or question is not applicable, indicate N/A. Doing Business As (DBA): If using a DBA, submit a Fictitious Business Name Statement.Application Processing Fee $780: Include a check or money order for $780 made payable to the Boardof Pharmacy. This fee is nonrefundable. To apply for a temporary license, an additional fee of $715 must be submitted in addition to theapplication processing fee. If other than a change of ownership and/or location, include awritten letter signed by the owner / partner / officer / member that clearly explains why it is inthe best interest of the public for the board to issue the facility a temporary license.Designated Representative-in-Charge (DRIC): The application shall include a Personal Background Affidavit (17A-37) form completed by the DRIC if the DRIC is a pharmacist licensed in the home state. California licensed designated representatives are not required to complete the Personal BackgroundAffidavit. Please request a license verification (17M-17) to be sent to the board if the DRIC is apharmacist licensed in the home state.A nonresident wholesaler facility must have its own DRIC responsible for the operations of thenonresident wholesaler. The application must list one designated representative, designatedrepresentative-reverse distributor, or a pharmacist to serve as the DRIC. If the wholesaler acts only as areverse distributor participating in the California Drug Take-Back Program, a designated representative-reverse distributor or a licensed pharmacist shall serve as the DRIC. The proposed DRIC shall be subjectto approval by the board. The board shall not issue a nonresident wholesaler license without anapproved DRIC for the nonresident wholesaler.The DRIC serves as supervisor or manager and is responsible for ensuring the nonresident wholesaler222scompliance with all state and federal laws and regulations pertaining to the wholesale operations. TheDRIC shall maintain an active license as a designated representative, designated representative-reversedistributor, or pharmacist at all times during which he or she is designated as the DRIC. If the DRIC is alicensed pharmacist he/she must have a current license in the home state of the facility.Organizational Chart: Submit a business ownership organizational chart that clearly documents theapplicant business222 ownership structure with the application. Include percentages owned by all partiesand lists the executive officers under the appropriate entity.License Verification: (17M-17): Submit a license verification from the home state regulatory agencyverifying the status of the license and the address of the nonresident wholesaler business.Copy of License: Provide a copy of the home state issued license. Section B Change Ownership / Change of Location A nonresident wholesaler license is nontransferable. A license is issued to the owner(s) and to the location of the facility. A change of ownership and/or change of location result in a new license number being issued to the new owner(s) and/or location. An application to the board and approval by the board should be submitted prior to the change occurring. Operating the facility prior to being issued a new license due to a change of ownership and/or location may be unlicensed activity. American LegalNet, Inc. www.FormsWorkFlow.com 3 of 6 17M-4 (rev 8/2018) In addition to the application requirements in Sections A, C, D, and E submit the following for a change of ownership application. Change of Ownership Documentation: Provide all required documents as listed in the appropriateownership business in Section C, including but not limited to:Seller222s Certification (17A-8)Copy of the signed purchase agreement.A copy of the final sale/closing documents will need to be submitted prior to the issuance of thelicense by the applicant applying for the nonresident wholesaler license. Section C Nonresident Wholesaler Ownership Documents (All Applicants) C1 - Individual Owner (Sole Proprietor) In addition to items listed in Sections A, D, and E submit the following: The individual owner needs to complete and submit a Personal Background Affidavit (17A-37)C2 226 Partnership In addition to items listed in Sections A, D, and E submit the following: Personal Background Affidavit (17A-37): Partner(s)Executive officer(s)(If the applicant business does not hold executive officers, list the executive officers for the parententity or the entity above the parent which holds the executive officers. The executive officer(s)must be identified by name and officer title on the organizational chart.)Business Background Affidavit (17A-18): The applicant businessThe parent entity(ies)Partnership Agreement: Current executed partnership agreement for the applicant business. C3 226 Corporation (Not Publicly Traded) In addition to items listed in Sections A, D, and E submit the following: Personal Background Affidavit (17A-37): Executive of