California State Board of Pharmacy STATE AND CONSUMER SERVICES 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 GOVERNOR EDMUND G. BROWN JR. DISCONTINUANCE OF BUSINESS Do not complete this form if you are changing ownership or location. Contact the Board immediately for the proper application packet. Please complete this form and forward it to the Board of Pharmacy at the address above. Include the large wall license, current renewal certificate and a copy of the inventory. Contact the Drug Enforcement Administration for instructions regarding their registration and order books. The telephone number of the office nearest you can be found at the DEA website at: http://www.usdoj.gov/dea/agency/domestic.htm. The following location will discontinue business: Name of licensed facility: Address of licensed facility: License Number: Number and Street Month, day, and year business will be discontinued: City State Zip Code DEA number (if applicable) Prescription inventory will be transferred to: Name of licensed facility: Address of licensed facility: Telephone number: ( License Number: Number and Street City State Zip Code DEA number (if applicable) ) Pursuant to sections 4081 and 4333 of the Business and Professions Code, all records of acquisition and disposition of dangerous drugs, including prescription files, must be retained for three (3) years from date of making, in a board-licensed facility. All records of acquisition and disposition of dangerous drugs will be maintained at the following location: Name and address of location: Telephone number: ( ) American LegalNet, Inc. www.FormsWorkFlow.com In addition, sections 4081 and 4333 of the Business and Professions Code require that records of disposition be maintained. A detailed inventory of all “dangerous drugs” (as defined in section 4022 of the Business and Professions Code) being transferred is required. An inventory of all dangerous drugs was taken on and a Month/day/year copy of the inventory has been given to the purchaser and the owner. A copy of the inventory is also attached to this certification. Name of Pharmacist-in-Charge: Pharmacist License Number Residence Address: Telephone number: I certify under penalty of perjury under the laws of the State of California to the truth and accuracy of all statements, answers and representations made on this form including all supplementary statements. Signature of Pharmacist-in-Charge Date As owner of the above listed permit, I can be reached at the following address after the business has been discontinued: Name of Owner: Telephone Number Residence Address: I certify under penalty of perjury under the laws of the State of California to the truth and accuracy of all statements, answers and representations made on this form including all supplementary statements. Signature of Owner Date PLEASE NOTE - the drugs cannot be transferred that do not conform to the standard and tests as to quality and strength provided in the latest edition of the USP or NF or which violate any provision of the Sherman Food, Drug and Cosmetic Law (Division 21, Commencing with Section 26000 of Health and Safety Code). 17M-8 (7/06) American LegalNet, Inc. www.FormsWorkFlow.com