California State Board of Pharmacy Fax (916) 574-8618 DEPARTMENT OF CONSUMER AFFAIRS CASH DEPOSIT IN LIEU OF BOND I/We , hereinafter referred to as Assignor, whose NAME OF APPLICANT/LICENSEE principal place of business is located at , do/does hereby assign and set over to the California State Board of Pharmacy (Board), hereinafter referred to as Board, all right, title and interest of any kind whatsoever, owned or held by Assignor in the cash sum of dollars ($ ) identified by Receipt Number , which is delivered to the Board pursuant to Section 4162 and/or Section 4162.5 of the Business and Professions Code and Section 995.710 of the Code of Civil Procedure. This assignment is binding on Assignor, his/her heirs, administrators, successors, and assigns, jointly or severally, and is conditioned that Assignor has made, or is about to make application to the Board for a license under Section 4162 and/or Section 4162.5 of the Business and Professions Code to act as a wholesaler or nonresident wholesaler. Assignor understands that the Board is not authorized to refund said cash deposit until sixty (60) days beyond the date upon which an owner ceases to be licensed by the Board, or ceases to do business as a wholesaler. Assignor further understands that the Board is authorized to reduce the sum of said cash deposit to the extent of all claims owing the California Board of Pharmacy arising from Assignor222s business activities as a wholesaler and reasonable attorney fees and administrative costs incurred in processing claims against such cash deposit; that the reduction of such deposit by any amount shall be grounds for denial of a renewal of the wholesaler license until such time as the cash deposit is restored to its original amount under the provisions of Section 4162 and/or Section 4162.5 of the Business and Professions Code. Executed in , on . City and StateDate Signature of Person Authorized to bind the businessPrinted or Typed name of Applicant/Licensee Exactly as shown above Type Name and Title of Person Authorized to bind the Business American LegalNet, Inc. www.FormsWorkFlow.com