California State Board of Pharmacy Fax (916) 574-8618 1625 N. Market Blvd, Suite N219, Sacramento, CA 95834 Phone (916) 574-7900 BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY DEPARTMENT OF CONSUMER AFFAIRS GOVERNOR EDMUND G. BROWN JR. Parent Corporation or Limited Liability Company Ownership Information Please print or type All blanks must be completed; if not applicable, enter N/A Name of parent corporation or limited liability company Address Name & address of premises Number and Street Number and Street City City State Telephone number State ( ) Zip Code Zip Code Is the parent corporation a subsidiary? Yes No If yes, name of parent corporation . This parent corporation must also complete a Parent Corporation or Limited Liability Company Ownership information form. Please attach an organization chart. A. Limited Liability Members or Manager(s) (Use additional sheets if necessary) Under the heading "Licensed as" list any state professional or vocational licenses held; e.g., pharmacist, physician, podiatrist, dentist or veterinarian, etc., and the license number (if applicable). Non-profit organizations must list the names and titles of persons holding corporate positions. Title Name Residence address & telephone number Licensed as, license no. and state(s) For Limited Liability Companies Only: We, the undersigned members, authorize _________________________________ to sign all Board of Pharmacy forms, documents and operating conditions on our behalf. B. Corporate Officers/Directors (Top 5 of each. Use additional sheets if necessary.) (Name of member) Under the heading "Licensed as" list any state professional or vocational licenses held; e.g., pharmacist, physician, podiatrist, dentist or veterinarian, etc., and the license number (if applicable). Non-profit organizations must list the names and titles of persons holding corporate positions. Title Name Residence address & telephone number Licensed as, license no. and state(s) American LegalNet, Inc. www.FormsWorkFlow.com C. Ow ners/Shareholders List all persons who own an interest (use additional sheets if necessary). List certificates chronologically, including active, cancelled, and pending issuance. If stock is pledged, include date, number of shares, and from whom to whom. Attach a copy of all stock certificates, transfer ledgers, and proof of purchase issued to date. Under the heading "Licensed as" list any state professional or vocational licenses held; e.g., pharmacist, physician, podiatrist, dentist or veterinarian, etc., and the license number (if applicable). To whom issued Residence address & telephone number Licensed as, license no. and state(s) licensed in Cert # % of Shares Date Issued Date cancelled D. Ownership If no stockholders exist, list all persons with a beneficial interest below. Name Residence address & telephone number E. Does 10% or more of the ownership rest with any other entity? Yes No If yes, please list below Name Residence address & telephone number American LegalNet, Inc. www.FormsWorkFlow.com This application must be approved by the California State Board of Pharmacy before a permit will be issued. If changes are made during the application process, you may need to submit a new application with the appropriate fees. 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 or her by the Board of Pharmacy, unless the records are identified as confidential information and exempted by section 1798.3 of the Civil Code. ALL OWNERS AND OFFICERS DESIGNATED ON THIS FORM MUST SIGN BELOW. 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 corporation or limited liability company named on this application form, 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 for which this application is made; and (4) all supplemental statements are true and accurate. Print Name______________________________ Print Name______________________________ Print Name______________________________ Print Name______________________________ Print Name______________________________ Print Name______________________________ Signature ______________________________Date _____________ Signature ______________________________Date _____________ Signature ______________________________Date _____________ Signature ______________________________Date _____________ Signature ______________________________Date _____________ Signature ______________________________Date _____________ 17A-33A (rev. 10/99) American LegalNet, Inc. www.FormsWorkFlow.com