22. Type of Application New HMDR (never licensed) NewHMDR (additional location) New HMDR (ownership change) New HMDR relocation (previous HMDR license number) (previous HMDR license number) Renewal of an existing HMDR HMDR Warehouse Only (storage) (HMDR license number) (retail facility HMDR license number) 23. Type of Business to be Conducted at this Location: RetailSales/Distribution Warehouse Only Businessdays and hours: 24. The applicant retailer will be selling the following products: (check all that apply) * Asterisk indicates prescription device -must have Pharmacist-in-charge (PIC) or a Licensed Exemptee on premises. ** Asterisks indicate product may be a prescription device.Respiratory Equipment/O2 Supplies* Incontinence Supplies Walkers, Canes, Commodes CPAPS, BiPAPS* Custom Wheelchairs Hospital Beds/Mattresses TENS Units** Power Wheelchairs ** Air pressure Mattresses** Infusion Pumps* Manual Wheelchairs Other227describe below or attach list of products Catheters* Nutritional Supplements CPM Machines Diabetic Test Supplies ** 2. DBA (List additional DBA222s on separate sheet if necessary.) 10. Facility Telephone Number 11. Facility FAX Number ( )( )3. Facility Address (number, street) 12. 24-Hour Emergency Telephone Number 13. E-mail Address ( )4. Facility Address (continued) 14. Correspondent (name and title) 5. City State ZIP Code 15. Correspondent Telephone Number 16. Correspondent FAX Number ( )( )6. Mailing Address (if different or P.O. Box number) 17. County 7. Mailing Address (continued) 18. Website (URL) 8. City State ZIP Code 19. Type of Ownership Individual/Sole Proprietorship Partnership Corporation/Limited Liability Company Other: 20. Corporate Name (if applicable) State of Incorporation 21. Owners222 or Officers222 Names and TitlesOwners222 or Officers222 Names and Title s (Attach a separate list if needed). State of California-Health and Human Services Agency California Department of Public Health Food and Drug Branch HOME MEDICAL DEVICE RETAILER LICENSE APPLICATION PLEASE COMPLETE THIS FORM FULLY227INCOMPLETE APPLICATIONS WILL BE RETURNED See page 2 for instructions NEWAPPLICANT RELOCATION OWNERSHIPCHANGE OWNERSHIPAND LOCATION CHANGE RENEWAL 1. Legal Name of Firm 9. Facility Operator (name and title) 25.If the HMDR facility will be selling/renting prescription devices, respiratory equipment, or medical oxygen:a.Will there be a pharmacist in charge (PIC) of operations at this location? Yes No (If Yes, attach a copy of PIC card) b.Will there be an HMDR exemptee in charge of operations at this location?Yes No (If Yes, attach a copy of exemptee license) Name: Exemptee License Number: Name: Ex emptee License Number: 26. Do you have a Medi-Cal or MediCare Provider number? (If currently applying for one, please check the Pending box) Medi - Cal Provider? Yes No Pending Medi c are Pr ovider? Yes No Pending 2 7 . Payment Codes (Check only one code 227 see page 2 for schedule.) MAKE CHECKS PAYABLE TO: CA DEPARTMENT OF PUBLIC HEALTH A227$1, B227$1, C227$53 See page 2 for mailing address. (Fee s are Non - Refunda ble) Under penalty of perjury, under the laws of the State of California, each person whose signature appears below, certifies and says: (1) he/she is the applicant, or one of the owners or managers of the applicant corporation, named in the foregoing application, duly authorized to make this application on its behalf; (2)that he/she has read the foregoing application and knows the contents thereof and that each and all statements therein made are true; (3) that no personother than the applicant or applicants has any direct or indirect interest in the applicant222s or applicants222 business to be conducted under the license(s) for whichthis application is made; (4) all supplemental statements are true and accurate. 2 8 . Signature of Applicant (original signature) Printed name Title Date License Number Expiration Date Date Received Payment Type Amount PLEASE DO NOT WRITE IN GRAY AREA ABOVE THIS LINE. 226 FOR STATE USE ONLY California Department of Public Health CDPH 8679 (/1) Fund 3018 Index 3018 Index 5624 PCA 76212 Receipt Source 125700 Agency Source 0049 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Home Medical Device Retailer License Application Instructions A separate application is required for each place of business. Please complete and/or amend this application as is most appropriate to your facility. Include the appropriate fee for each application as indicated in the fee schedule and payable to: CA DEPARTMENT OF PUBLIC HEALTH. This fee must accompany this application. Without the fee the application cannot be processed. Unsigned or incomplete applications cannot be processed. The following are further instructions on how to complete this application: Do not leave any sections blank. New Applicant / Renewal Applicant: Place an (X) in the box next to New Applicant if your firm has not previously applied for a Home Medical Device Retailer License at this location while under the current ownership. Place an (X) in the box next to Renewal Applicant if your firm has already obtained a Home Medical Device Retailer License for this location, and you are renewing that license. If your firm has changed location, ownership, or both, place an (X) in the box adjacent to the appropriate response. Check one box only. 1.Legal Name of Firm: Enter full name of business, corporation, company, or organization applying for licensure.2.DBA: Enter any other name(s) your company is doing business as.3.2265. Facility Address: Enter the number, street, city, state, and zip code for this facility location. 6.2268. Mailing Address: Enter the full mailing address if different from the facility address. Facility Operator: Enter the full name of the person who manages the operations at this facility and their title.Facility Telephone Number: Enter daytime business telephone number of this facility. Facility FAX Number: Enter facility FAX number. 24-Hour Emergency Telephone Number: Enter telephone number to be called in the event of an emergency. E-mail Address: Enter facility e-mail address. Correspondent: Enter the name of the person to contact for information regarding this application and their title. Correspondent Telephone Number: Enter the daytime business telephone number of the contact person. Correspondent FAX Number: Enter the daytime business FAX number of the contact person. County: Enter the county where your facility is located. Website: Enter the website address for your business, if applicableType of Ownership: Place an (X) in the box next to the appropriate legal description of the facility222s ownership.Corporate Name: Enter corporate name if applicable. Enter state of incorporation if applicable.Owners222 or Officers222 Names: List the business owners222 or officers222 names and titles. Attach a list if needed. Type of Application: Place an (X) in the box next to the type of application you are submitting.Type of Business Conducted: Place an (X) in the box adjacent to the type of business being conducted at this location and list business days andhours. Type of Products Selling: Place an (X) in the box adjacent to the type of products your business will be selling. Check all that apply.Selling or Renting Prescription Devices, Medical Oxygen, or Respiratory Equipment: Place an (X) in the boxes next to your answer for questionand b. If you answered yes, provide the name of the exemptee and their license number.Medi-Cal or Medicare Provider: Place an (X) in the boxes adjacent to your answer to each question on provider types. Payment Codes: Your license fee is based on the type of activity at your facility. Based on the chart below, place an (X) in the correct payment codebox on the first page (mark only one box A226C).License Category Fee Interval of Renewal and Fees Payment Code New Instate Firm $1,.00 First license or Relocation, Ownership Change, Relocation and Ownership Change A Renewal $1,.00 Annually on renewal B Warehouse only $53.00 First license or Relocation, Ownership Change, Relocation and Ownership Change and Annual renewal C ** LICENSE FEES ARE NON-REFUNDABLE AND NON-TRANSFERABLE TO OTHER LOCA