California State Board of Pharmacy 1625 N. Market Blvd, Suite N219, Sacramento, CA 95834 Phone (916) 574-7900 Fax (916) 574-8618 www.pharmacy.ca.gov BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY DEPARTMENT OF CONSUMER AFFAIRS GOVERNOR EDMUND G. BROWN JR. SOLE OWNER INSTRUCTIONS An application for a wholesaler must include: Completed Application for Wholesaler License (from 17A-13 WLS) $780 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 (form 17A-37) Copy of Request for Live Scan Service Form verifying that your fingerprints have been scanned and all applicable fees have been paid. License verification from each state licensing authority where a license has been granted (form 17M-17) Executed Seller's Certification (form 17A-8), if the application is for a change of ownership of an existing license. 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. 17M-18 WLS (Rev 7-14) American LegalNet, Inc. www.FormsWorkFlow.com