South Carolina Department of Labor, Licensing and Regulation South Carolina Board of Pharmacy P.O. Box 11927 • Columbia, SC 29211-1927 Phone: 803-896-4700 • Fax: 803-896-4596 • www.llronline.com/POL/Pharmacy/ NOTIFICATION OF PERMIT HOLDER CHANGE I hereby certify that as Permit Holder, I will be responsible for all professional duties connected with the proper and lawful conduct of this facility. _____________________________________________ Signature of Permit Holder __________________________ Date Please print the following information: Name & Title of Permit Holder: _________________________________________________________________________________________________ Name of Permitted Facility:___________________________________________________________________________ Permit #_____________________________________ Phone #_________________________________________ Address of Facility__________________________________________________________________________________ Email address of Permit Holder:_______________________________________________________________________ This form must be completed and returned to the Board office within ten days of the change in permit holder. A faxed or emailed copy is acceptable. An updated permit listing the new permit holder will be mailed to the facility. American LegalNet, Inc. www.FormsWorkFlow.com