.. .. + + .. Licensing Program 2005 Evergreen Street, Suite 1200 MEDICAL BOARD Sacramento, CA 95815-5401 Phone: (916) 263-2382 OF CALIFORNIA Fax: (916) 263-2487 Protecting consumers by advancing high quality, safe medical care. www.mbc.ca.gov Gavin Newsom, Governor, State of California | Business, Consumer Services and Housing Agency | Department of Consumer Affairs FICTITIOUS NAME PERMIT NOTIFICATION OF RENEWAL/HOLD RELEASE Fictitious Name: FNP #: Current Physical SS#/FEIN#: Practice Address: (No PO Box) Phone #: Renewal Fee: $ Our records indicate that you are presently doing business as: Corporation Partnership Individual (Sole Proprietor) A hold has has not been placed on your Fictitious Name Permit. In order for the hold to be removed, this form must be completed in its entirety and signed by a current owner. Refer to the enclosed attachment indicating the current owner(s). Note: A fictitious name permit is not transferable. If a medical practice is purchased by another physician, theformer owner must submit an 223Application for Cancellation of a Fictitious Name Permit224 to cancel the permit and the new owner must submit a 223Fictitious Name Permit Application.224 Both forms should be mailed at the same time to assure the name will be available to the new owner. If you are doing business as a corporation or as a partnership and wish to add/delete shareholders or partners, please provide the following information in the table below. Signatures are required to associate or disassociate shareholders or partners. A signature at the bottom of this form also is required to change the address or renew the permit. Refer to attachment for current owners. Doctor222s Name (print or type) License # Association Disassociation Signature Date Date I declare under penalty of perjury under the laws of the State of California that I have read the foregoing notification and all attachments thereto and know the contents thereof. I have the legal authority to act on behalf of the above-stated entity and the information contained herein is true and correct. Print or Type Name Signature Date License # FNP-004 (Revised 01/2019) American LegalNet, Inc. www.FormsWorkFlow.com