Financial Affidavit In Support Of Application Form. This is a California form and can be use in Board Of Pharmacy Statewide.
Tags: Financial Affidavit In Support Of Application, 17A-2, California Statewide, Board Of Pharmacy
California State Board of Pharmacy DEPARTMENT OF CONSUMER AFFAIRS Fax (916) 574-8618 www.pharmacy.ca.gov Financial Affidavit in Support of Application All items of information 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 registration under the California Pharmacy Law. The official responsible for information maintenance is the executive officer, , . The information may be transferred to anothergovernmental agency such as a law enforcement agency if necessary for it to perform its duties. Each individual has theright to review the files or records maintained on them by our agency, unless the records are identified as confidentialinformation and exempted by section 1798.3 of the Civil Code.Please print or type All blanks must be completed; if not applicable, enter N/A Name of Corporation, Partnership or Individual Owner: Address of Corporation, Partnership or Individual Owner: Name of Pharmacy, Hospital, Wholesaler, etc: Premises Address: Number and Street City Zip Code Telephone Number: l i) it willi$ l. $ Indicate what part of the totainvestment wll be in cash, and from what source(s be or has been derved. Please attach documentation. Source: List all other sources of funding for the pharmacy and how it wil be paid. Provide the name, address, telephone number and amount. Use additional sheets if necessarySource: If the pharmacy is franchised, list the name of franchisor: American LegalNet, Inc. www.FormsWorkFlow.com Who will be the primary wholesaler for dangerous drugs and/or dangerous devices? Please attach a photocopy of the approved application filed with the wholesaler. Name of primary Wholesaler Telephone number Address of Wholesaler Number & Street City State Zip Code Who will be the secondary wholesaler for dangerous drugs and/or dangerous devices? Please attach a photocopy of the approved application filed with the wholesaler. Name of secondary Wholesaler Telephone number Address of Wholesaler Number & Street City State Zip Code Business Bank Name & Address (list all accounts for the pharmacy) Telephone Number Account Number Balance of Account Please submit a copy of most recent bank statement for each bank account listed above. List all individuals authorized to sign on business bank account. Signature Name (please print) Title ( ) City State Zi $ $ Name of bookkeeper/accountant for applicant premises: Telephone Number Address of bookkeeper/accountant: Number and Street p Code Estimated annual gross salesEstimated annual purchases American LegalNet, Inc. www.FormsWorkFlow.com APPLICANT(S) AUTHORIZATION FOR DISCLOSURE OF FINANCIAL RECORDS For a period of nine months, from this date, for the purpose of authorizing the Board of Pharmacy to conduct an investigation on my/our qualifications pursuant to section 4207 of the Business and Professions Code, I/we hereby authorize the Board of Pharmacy, or any of its authorized personnel to examine and secure copies of financial records consisting of signature cards, checking and savings accounts, notes and loan documents, deposit and withdrawal records, and escrow documents of my/our financial institution(s) or any financial records established in connection with this business. I/we also authorize the Board of Pharmacy, or any of its authorized personnel, to examine and secure copies of any business records or documents established in connection with this business, including, but not limited to, those on file with my/our bookkeeper/accountant or with the escrow holder. I/we agree to furnish current financial information on the annual renewal if requested by the Board of Pharmacy. Applicant understands that falsification of the information on this form may constitute grounds for denial or revocation of the license. I hereby 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 in the foregoing application, including all supplementary statements. If corporation owned, one corporate officer must sign; if partnership owned, all partners must sign. Signature of corporate officer, partner or owner Name (please print) Title Date Signature of corporate officer, partner or owner Name (please print) Title Date Signature of corporate officer, partner or owner Name (please print) Title Date Signature of corporate officer, partner or owner Name (please print) Title Date Signature of corporate officer, partner or owner Name (please print) Title Date Placeic) Date Attest (Notary Publ17A-2 (Rev. 10/00) American LegalNet, Inc. www.FormsWorkFlow.com