California State Board of Pharmacy STATE AND CONSUMER SERVICES AGENCY DEPARTMENT OF CONSUMER AFFAIRS ARNOLD SCHWARZENEGGER, GOVERNOR 1625 N. Market Blvd, Suite N219, Sacramento, CA 95834 Phone (916) 574-7900 Fax (916) 574-8618 Website - www.pharmacy.ca.gov SELLER’S CERTIFICATION INSTRUCTIONS: This form is to be completed by the seller and submitted by the prospective owner with the application for a change of ownership. Attach a copy of the pending purchase agreement. NOTICE: The current permit is not transferable and the current owner of record must maintain operations and control of the licensed premises (including renewing the permit) until a new application is approved by the Board of Pharmacy. The new owner must complete and attach the new application to this document. (Proof of authority to sell by any person, except a person whose name appears on the original permit, must accompany this certification.) All blanks must be completed; if not applicable enter N/A (Please print or type) This will certify that (name of individual, partnership* or corporation – “seller”) has agreed that on “seller” shall transfer month/day/year (all, half, etc.) of the right, title and interest in (name of premises) (permit number) located at (street number and name) (city) (state) (zip code) To (name of buyer(s)) *IF A PARTNERSHIP, LIST THE NAMES OF ALL PARTNERS (all names must be listed) On completion of this sale and approval of the new permit, the original permit, and the current renewal must be returned to the California State Board of Pharmacy for cancellation, before the new permit will be released. 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 licensee, general partner or an executive officer of the corporate licensee named in this Seller's Certification, duly authorized to make this sale; and (2) all statements made in this Seller's Certification are true and correct. If the seller is a partnership, all partners must sign below. Signature of Seller Name (please print) Title Date Signature of Seller Name (please print) Title Date Signature of Seller Name (please print) Title Date 17A-8 (Rev. 12/04) American LegalNet, Inc. www.FormsWorkflow.com