California State Board of Pharmacy 1625 N. Market Blvd, N219, Sacramento, CA 95834 Phone (916) 574-7900 Fax (916) 574-8617 www.pharmacy.ca.gov STATE AND CONSUMER SERVICES AGENCY DEPARTMENT OF CONSUMER AFFAIRS GOVERNOR EDMUND G. BROWN JR. REQUIREMENTS FOR FILING A COMMUNITY PHARMACY APPLICATION IMPORTANT: Please follow these instructions completely. Failure to submit the necessary items will delay the processing of your application. If the number of forms provided is not sufficient, please make photocopies. You will be notified of any major deficiencies in your application. Please allow approximately 60 days from the time your application packet is complete before calling the Board of Pharmacy. Any forms that have been previously submitted with another application will not be pulled from the file. You must complete and submit all of the requested information. If you would like notification that the board has received your application, please submit a stamped postcard addressed to yourself. SUMMARY OF CHECKLIST Section A Requirements for all applicants except government owned, Indian tribe owned, or change of location. Note: All pharmacy 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 $250.00 temporary permit fee must also be submitted. Section B Forms required for an applicant who is filing as an individual owner Section C Forms required for an applicant whose ownership is a partnership Section D Forms required for an applicant who is filing as a corporation Section E Forms required for an applicant who is filing as a limited liability company Section F own Requirements for state, city or county owned pharmacy and city or county ed jail pharmacies Section G Requirements for Native American tribe owned pharmacy Section H Requirements for non-Native American owned but operating on tribal lands Section I Requirements for change of location only (no ownership change) American LegalNet, Inc. www.FormsWorkFlow.com CHECKLIST FOR FILING A COMMUNITY PHARMACY APPLICATION Section A All Applicants [ ] 1. Application (17A-4) and the non-refundable processing fee of $400. [ ] 2. Ownership form a. b. [ ] Corporation OR Limited Liability Company (17A-33 ) OR Partnership or Individual (17A-34) 3. Financial Affidavit in Support of Application (17A-2) (NOTE - Not needed for a change of location or non-profit organization) AND [ ] 4. Approved wholesale credit application or wholesale agreement (NOTE - Not needed for a non-profit organization) [ ] 5. Copy of the lease agreement [ ] 6. Seller’s Certification for a Pharmacy (17A-8) (If applicable) This is only required for an application for a change of ownership and it must be submitted by the prospective owner(s). Section B Individual Owner who is not incorporated In addition to items listed in Section A, the following must be submitted: [ ] 1. Certification of Personnel (17A-11) [ ] 2. Individual Personal Affidavit (17A-27) [ ] 3. Individual Financial Affidavit (17A-26) [ ] 4. Copy of Request for Live Scan Service Form verifying that your fingerprints have been scanned and all applicable fees have been paid. Please refer to fingerprint instructions on page 7. [ ] 5. Certification of Personnel (17A-11) for the pharmacist-in-charge -2American LegalNet, Inc. www.FormsWorkFlow.com Section C Partnership In addition to items listed in Section A, the following must be submitted: [ ] 1. Each partner must submit: • Certification of Personnel (form 17A-11) • Individual Personal Affidavit (17A-27) • Individual Financial Affidavit (form 17A-26) • Copy of Request for Live Scan Service Form verifying that your fingerprints have been scanned and all applicable fees have been paid. Please refer to fingerprint instructions on page 7. [ ] 2. Certification of Personnel (17A-11) for the pharmacist-in-charge [ ] 3. Signed Partnership Agreement If the partners are a corporation or a limited liability company (LLC), then complete and provide the same documents required of corporations (see section D). Section D Corporations In addition to items listed in Section A, the following must be submitted: The first line corporation over the pharmacy needs to complete a form 17A-33. Each remaining parent corporation, over the first line corporation, needs to complete a form 17A-33A. For Profit For the named corporation on the application, or person(s) who owns an interest in, the corporation named on the application the following is required: [ ] 1. Each corporate officer, major shareholder, and director must submit: • Certification of Personnel (17A-11) • Individual Personal Affidavit (17A-27) • Individual Financial Affidavit (form 17A-26) • Copy of Request for Live Scan Service Form verifying that your fingerprints have been scanned and all applicable fees have been paid. Please refer to fingerprint instructions on page 7. [ ] 2. Certification of Personnel (17A-11 for the pharmacist-in-charge) [ ] 3. Articles of Incorporation endorsed by the Secretary of State. -3American LegalNet, Inc. www.FormsWorkFlow.com [ ] 4. Statement a. Statement of Information endorsed by the Secretary of State. An endorsed copy must be requested from the Secretary of State. OR b. Statement by Foreign Corporation endorsed by the California Secretary of State. This is only required if the named corporation on the application is incorporated outside of California. [ ] 5. By-laws Non-Profit For the named corporation on the application, or person(s) who owns an interest in, the corporation named on the application, the following is required: [ ] 1. Statement of Information endorsed by the Secretary of State. [ ] 2. By-laws [ ] 3. Articles of Incorporation endorsed by the Secretary of State. [ ] 4. Each corporate officer, shareholder, and director must submit: • [ ] Certification of Personnel (17A-11) 5. Certification of Personnel (17A-11) for the pharmacist-in-charge Publicly Traded Corporation [ ] 1. A copy of the corporation’s 10K filing with the Securities Exchange Commission. [ ] 2. A list of the five largest shareholders who own 5% or more of stock which requires a filing with the Securities Exchange Commission. If the shareholder is an individual, include name, title and professional license (if applicable). Also, identify if the shareholder is a bank, trust company or financial institution to which a license is issued in a fiduciary capacity. -4American LegalNet, Inc. www.FormsWorkFlow.com Section E Limited Liability Company (LLC) In addition to items listed in Section A, the following must be submitted: The first line limited liability company over the pharmacy needs to complete a form 17A-33A. Each remaining company over the first line limited liability company also needs to complete a form 17A33A. [ ] 1. Each member/manager must submit: • Certification of Personnel (17A-11) • Individual Personal Affidavit (17A-27) • Individual Financial Affidavit (form 17A-26) • Copy of Request for Live Scan Service Form verifying that your fingerprints have been scanned and all applicable fees have been paid. Please refer to fingerprint instructions on page 7. [ ] 2. Certification of Personnel (17A-11 for the pharmacist-in-charge) [ ] 3. Articles of Organization endorsed by the Secretary of State [ ] 4. Statement of Information endorsed by the Secretary of State [ ] 5. Copy of limited liability company agreement Section F State, City or County Owned Pharmacy In addition to items listed in Section A, the following must be submitted: [ ] 1. Application (17A-4) [ ] 2. Completed Certification of Personnel (17A-11) for: a. Administr ator b. phar macist-in-charge [ ] 3. A letter of verification from the county public health department or the board of supervisors indicating that the facility is government owned [ ] 4. The name of the Director of Public Health or the responsible party for the pharmacy operation [ ] 5. A copy of the organizational structure -5American LegalNet, Inc. www.FormsWorkFlow.com Correctional facilities/city or county owned jail facilities [ ] 1. Application (17A-43) [ ] 2. Completed Certification of Personnel (17A-11) for: a. war den b. med ical director c. phar macist-in-charge Section G Native American Owned In addition to items listed in Section A, the following must be submitted: [ ] 1. Application (17A-4) and the non-refundable processing fee of $400. [ ] 2. Official documents from the U.S. Department of Interior, Bureau of Indian Affairs, identifying the official tribe. [ ] 3. A copy of the constitution and by-laws establishing the tribal council that will be the governing entity of the pharmacy. [ ] 4. Tribal council members and the administrator/CEO must submit: • Certification of Personnel (17A-11) • Copy of Request for Live Scan Service Form verifying fingerprints for the tribal council and the administrator/CEO have been scanned and all applicable fees have been paid. Please refer to fingerprint instructions on page 7. [ ] 5. Certification of Personnel (17A-11) for the pharmacist-in-charge. Section H Non-Native American Owned but Operating on Tribal Lands In addition to items listed in Section A, the following must be submitted: If the non-Native American owner is a corporation: [ ] 1. All requirements listed in Section A. [ ] 2. Articles of incorporation endorsed by the Native American tribe. [ ] 3. Statement of Information endorsed by the Native American tribe. [ ] 4. AND all other requirements of corporate owners listed in section D, (except the articles of incorporation and the statement by domestic stock must be endorsed by the Native American tribe and not by the Secretary of State). If the non-Native American owner is a sole owner or partnership: [ ] 1. All requirements listed in Section A. -6American LegalNet, Inc. www.FormsWorkFlow.com [ ] 2. Documents describing the agreements with the Native American tribe to operate the pharmacy on tribal land. [ ] 3. AND all other requirements of sole owners or partnership listed in Section B or Section C respectively. Section I Change of Location ONLY (no ownership change) [ ] 1. Application (17A-4) and the non-refundable processing fee of $100. [ ] 2. Ownership a. Corporation or Limited Liability Company (17A-33) OR b. Partnership or Individual (17A-34) [ ] 3. Copy of the lease agreement. [ ] 4. Each corporate officer, shareholder, and director must submit a. Certification of Personnel (17A-11) b. Individual Personal Affidavit (17A-27) c. Completed fingerprint card and $51 fingerprint processing fee. [ ] 5. Pharmacist-in-charge must submit a Certification of Personnel (17A-11) -7American LegalNet, Inc. www.FormsWorkFlow.com Fingerprint Requirements California Residents The board will only accept Live Scan Service Forms from California residents. Complete a Live Scan Request form and take all 3 copies to a Live Scan site for fingerprint scanning. Please refer to the Instructions for completing a "Request for Live Scan Service" form. Live Scan sites are located throughout California. For more information about locating a Live Scan site near you, visit the Department of Justice website at http://ag.ca.gov/fingerprints/publications/contact.htm or the sources listed on the bottom of the instructions for completing a "Request for Live Scan Service" form. The lower portion of the Live Scan Request form must be completed by the Live Scan operator verifying that your prints have been scanned and all applicable fees have been paid. Attach the second copy of the form to your application and submit to the board. Non California Residents If an owner, partner, corporate officer, major shareholder or director reside out of state they must submit rolled fingerprints on cards provided by the board and include a separate fee of $51 ($32 California Department of Justice (DOJ) fee and $19 FBI fingerprint processing fee). (Live Scan processing fees are paid directly at the Live Scan site.) You may contact the board to request fingerprint cards at (916) 574-7900. You may also request cards on our website at www.pharmacy.ca.gov. Fingerprints submitted on cards should be taken by a person professionally trained in the rolling of prints. Fingerprint clearances from cards take approximately six weeks (live scan is faster). Poor quality prints may result in rejection and will substantially delay licensing as additional fingerprint cards will be required from you for processing. The board will only accept fingerprint cards from residents outside of California. 17M-45 (1/08) -8American LegalNet, Inc. www.FormsWorkFlow.com