The University of the State of New York THE STATE EDUCATION DEPARTMENT Office of the Professions New York State Board of Pharmacy 89 Washington Avenue Albany, NY 12234-1000 Phone: 518-474-3817 ext. 130 E-mail: pharmbd@mail.nysed.gov Lawrence Mokhiber, Executive Secretary 1 NON-RESIDENT NOTICE OF CHANGE IN OFFICERS AND/OR OWNERSHIP The Pharmacy Board must be notified within 30 days of any change in ownership or officers – Regulations of the Commissioner 63.6(a)(3). Type of establishment (check one) Pharmacy Repacker Medicinal Gases 2 Manufacturer Repacker Wholesaler/Distributor a. Name of establishment (as registered): _________________________________________________________________________________ b. Registration number: ________________________________________________________________________________________________ c. Address: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ d. 3 Phone: _________________________ Fax: _________________________ E-mail address: _______________________________________ Give full name and title for each corporate officer, partner, member or owner. Check the box of the new officer, provide signature for new officer(s). USE ADDITIONAL SHEETS IF NECESSARY. Last Name, First Name (please print) Signature of New Owner or Officer Date / / / / / / / / Title (please print) Last Name, First Name (please print) Signature of New Owner or Officer Date Title (please print) Last Name, First Name (please print) Signature of New Owner or Officer Date Title (please print) Last Name, First Name (please print) Signature of New Owner or Officer Date Title (please print) Form OOS 522, Page 1 of 2, (Rev. 10/07) American LegalNet, Inc. www.FormsWorkFlow.com 4 Contact person to clarify information provided on this application.: Name __________________________________________________________________________________ Telephone: ______________________________________________ Fax: ___________________________________________________ E-mail _________________________________________________________________________________ 5 ATTESTATION (Notarization required.) REGISTRANT The undersigned affirms under penalty of perjury that the answers and statements that he/she has made in the above application are true. Print Name: ______________________________________________________________________________________ Title: __________________________________________________________________________________________ Signature of Registrant: ______________________________________________ Date: _______ / _______ / _______ (Individual Owner, Partner, Corporate Officer, or *Other Authorized Person) Month Day Year *Power of attorney must be submitted NOTARY State of __________________________________________ County of _______________________________________ On the ____________ day of ______________________ in the year __________, before me personally appeared the above registrant ____________________________________________, personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to this application, and acknowledged to me that he/she executed the application and swore that the statements made by him/her in the application and all supporting materials are true, complete, and correct and have been made and given with the intent of having the New York State Education Department and the New York State Board of Pharmacy rely on the truth thereof. Notary Public signature _____________________________________________________________________________ Notary Commission Expires: ________ / ________ / ________ Month Day Year Notary Stamp Form OOS 522, Page 2 of 2, (Rev. 10/07) American LegalNet, Inc. www.FormsWorkFlow.com