Limited Liability Company Instructions Form. This is a California form and can be use in Board Of Pharmacy Statewide.
Tags: Limited Liability Company Instructions, 17M-4, California Statewide, Board Of Pharmacy
California State Board of Pharmacy 1625 N Market Blvd, N219, Sacramento, CA 95834 Phone (916) 574-7900 Fax (916) 574-8618 www.pharmacy.ca.gov STATE AND CONSUMER SERVICES AGENCY DEPARTMENT OF CONSUMER AFFAIRS GOVERNOR EDMUND G. BROWN JR. LIMITED LIABILITY COMPANY INSTRUCTIONS An application for a wholesaler must include: Completed Application for Wholesaler License (form 17A-59 WLS) $600 application processing fee made payable to the “California State Board of Pharmacy” Report of the designated representative-in-charge* (form 17A-3) Personal Background Affidavit for the top five members listed on the application** (form 17A37) Copy of Request for Live Scan Service Form for the top five members listed verifying that fingerprints have been scanned and all applicable fees have been paid. License verification from each state licensing authority where a license has been issued to the applicant (form 17M-17) Business Background Affidavit (form 17A-18). Articles of Organization endorsed by the California Secretary of State. Executed Seller’s Certification (form 17A-8), if the application is for a change of ownership of an existing license. This application should be completed and signed by an individual authorized to act for and bind the limited liability company, such as a member, manager, or principal/executive officer (e.g., president, CEO, chairperson). Note: All wholesaler change of ownership applications will be considered for temporary permits. Whenever a change of ownership occurs, either a temporary permit will be pursued or operation must stop. In addition to the regular items required for this application, a $550.00 temporary permit fee must also be submitted. *Under California law, the name used to describe any individual who is in charge of any wholesale drug premises (in California or elsewhere) will change on January 1, 2006, from the former name, exemptee, to designated representative. For conventional use, the board will refer to such an individual as a designated representative throughout this application. **In addition, if a member listed on the application is not a natural person, a Business Background Affidavit (form 17A-18) must also be completed by an individual authorized to act for and bind the LLC. This person must also complete a Personal Background Affidavit (form 17A-37) and submit a Copy of Request for Live Scan Service Form verifying that fingerprints have been scanned and all applicable fees have been paid. If this person resides out of state, one set of two completed fingerprint cards and the fingerprint processing fee of $66.00 must be submitted. 17M-4 WLS (1/08) American LegalNet, Inc. www.FormsWorkFlow.com