California State Board of Pharmacy STATE AND CONSUMERS AFFAIRS 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 CLINIC PERMIT APPLICATION Please print or type All blanks must be completed. If not applicable enter N/A Name of Clinic: Clinic telephone number: Address of Clinic: Number and street City State Zip Code Type of Clinic: Community Free Multi-Specialty Surgical Ambulatory Surgical Non Profit Other Profit Indicate whether this application is for: New Clinic Change of Location Change of Ownership If change of ownership or change of location, indicate previous name, address and license number of clinic: Type of ownership: Individual Partnership Date of last inspection by the Department of Health Services: Corporation Government Limited Liability Company Are you Medicare Certified? If yes, attach a copy of your current medicare certificate. Yes No Anticipated first day of business: Mail all correspondence to the following address below. If correspondence should be mailed to the clinic please insert "Same as Clinic." Name and telephone number of contact person to clarify information provided on this application. ( e-mail address ) Continue on reverse For Office Use Only Staff Review Articles of Inc or Org Partner Agreement Seller's Cert DHS lic/waiver Policy & Proc Medicare cert Cashier Approval_________________ Cashiering #___________________ Denied__________________ Date_________________________ Date____________________ Amount of Fee_________________ Page 1 of 4 American LegalNet, Inc. www.FormsWorkflow.com Ownership Information Name of Sole Owner (If applicable) Address *Social Security Number City number and street Name of Partner (If applicable) Address State *FEIN Number City number and street Name of Partner (If applicable) Address Telephone Number Telephone Number State *FEIN Number City number and street State Zip Code Telephone Number City number and street Zip Code Telephone Number Name of Corporation/Limited Liability Company (If applicable) Address Zip Code State Zip Code Print below the name, title, address and license number of all the clinic owners. This includes the individual owner, all partners, corporate officers, members, managers. Under the heading "Licensed as" list any state professional or vocational licenses held; e.g., pharmacist, physician, podiatrist, dentist or veterinarian etc., and license number. Non-profit organizations must list the names and titles of persons holding corporate positions. Attach additional sheet if necessary. Title Name Residence Address Licensed as and license number *Disclosure of your U.S. social security account number, or federal employer identification number (FEIN) if you are a partnership, is mandatory. Section 30 of the Business and Professions Code, section 17520 of the Family Code, and Public Law 94-455 (42 USC 405(c)(2)(C)) authorize collection of your social security account number. Your social security account number or FEIN will be used exclusively for tax enforcement purposes, or for purposes of compliance with any judgment or order for child or family support in accordance with section 17520 of the Family Law Code. If you fail to disclose your social security account number or your FEIN, your application will not be processed and you may be reported to the Franchise Tax Board, which may assess a $100 penalty against you. FEDERAL EMPLOYEE ID NUMBER (FEIN): Page 2 of 4 American LegalNet, Inc. www.FormsWorkflow.com Name of Professional Director: Residence Address License Number City State Name of Administrator: Residence Address License Number City State Name of Consulting pharmacist: Residence Address Zip Code Zip Code License Number City State Zip Code I certify that the policies and procedures of the clinic's drug distribution service are consistent with the promotion and protection of health and safety of the public regarding inventories, security, training, protocol development, recordkeeping, packaging, labeling dispensing, and patient consultation. Signature of Consulting Pharmacist Name (please print) Date PLEASE READ CAREFULLY This application must be approved by the California State Board of Pharmacy before a clinic permit will be issued. If changes are made during the application process, you may need to submit a new application with the appropriate fees. Any application not completed within 60 days of receipt may be deemed withdrawn by the Board of Pharmacy. Fees applied to this application are not transferable and are not refundable. Any material misrepresentation in the answer of any question is grounds for refusal or subsequent revocation of a license, and is a violation of the Penal Code of California. All items of information requested in this application are mandatory. Failure to provide any of the requested information will result in the application being rejected as incomplete. The information will be used to determine qualifications for licensure under California Pharmacy Law. The officer 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 on him/her by the Board of Pharmacy, unless the records are identified as confidential information and exempted by Section 1798.3 of the Civil Code. Page 3 of 4 American LegalNet, Inc. www.FormsWorkflow.com Under penalty of perjury, under the laws of the State of California, each person whose signature appears below, certifies and says that: (1) he/she is the owner or an officer of the applicant corporation named in the foregoing application, duly authorized to make this application on its behalf and is at least 18 years of age; (2) he/she has read the foregoing application and knows the contents thereof and that each and all statements therein made are true; (3) 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(s) for which this application is made; (4) the clinic complies with all applicable laws and regulations of the State Department of Health Services relating to drug distribution (Title 22, Article 4); (5) the professional director is responsible for safe, orderly and lawful provisions of the pharmacy service; (6) all supplemental statements are true and accurate. I am also aware that I am bound by the applicable Federal and State laws and regulations pertaining to the practice of pharmacy; and (7) the transfer application may be withdrawn by either the applicant or the licensee with no resulting liability to the Board of Pharmacy. Signature of Professional Director Name (please print) Title Date Signature of Administrator Name (please print) Title Date Signature of Corporate officer, owner, or partner Name (please print) Title Date Signature of Corporate officer, owner, or partner Name (please print) Title Date 17A-42 (Rev. 3/07) Page 4 of 4 American LegalNet, Inc. www.FormsWorkflow.com