Wisconsin Department of Safety and Professional Services Mail To: P.O. Box 8935 FAX #: Phone #: Madison, WI 53708-8935 (608) 261-7083 (608) 266-2112 1400 E. Washington Avenue Madison, WI 53703 E-Mail: web@dsps.wi.gov Website: http://dsps.wi.gov PHARMACY EXAMINING BOARD CHANGE OF NAME, OWNERSHIP, LOCATION OR ADDRESS FOR A PHARMACY, WHOLESALE DISTRIBUTOR OR MANUFACTURER The following chart sets forth when a change of ownership occurs which requires a new license. To obtain a new application go to dsps.wi.gov OWNER TRANSACTION CHANGE OF OWNERSHIP Individual Individual Individual YES NO [only a change in business form of owner] YES Partnership Sells facility to another “Incorporates” him or herself and there are no other shareholders Incorporates and adds shareholders other than self, or goes into partnership with other(s) Sells facility to another Members of partnership change and dissolves; e.g., individual(s) leaves Members of partnership change, but partners vote not to dissolve unanimously or by partnership agreement Partner Partnership decides to incorporate itself Corporation Corporation Change in shareholders (including sale of all stock) Sells all assets (as opposed to stock) Corporation Becomes a subsidiary or division of another corporation Corporation Merges into/or consolidates with another corporation and loses corporate “identity” Partnership Partnership Partnership 1 YES YES NO NO [again, only a change business form--as long as no shareholders added who were not partners before] NO [Corporation owns facility--not shareholders] YES [One asset being sold is facility; corporation no longer owns it after asset sale] NO [Corporation still owns facility, regardless of who owns corporation] YES Limited Liability Companies created under Ch. 183, Stats., are the same as Corporations for change of ownership. If you answered “yes” to any of the above items, you can not renew your current license. You must go the Department website at: www.dsps.wi.gov. Choose the appropriate profession, view the application/forms page and follow all application instructions. If none of the above pertains to your situation, view the Frequently Asked Questions for further information. Q: We would like to change our DBA name, how do we notify the Board? A: Please submit a letter to the board indicating that this is a name change only and change of ownership has not occurred. Include your current and new name with your WI license number. To receive a new license a $10.00 fee is required. Make checks payable to the Department of Safety and Professional Services. Q: We would like to change our address, how do we notify the Board? A: How to file can be found on the Department website at: www.dsps.wi.gov Go to "Application/Forms” link posted under your profession. If this is a postal change only and no physical move has taken place, submit a letter to the board indicating that this is a postal change only and no change of location has occurred. Include your current /new address with your WI license number. To receive a new license a $10.00 fee is required. Make checks payable to the Department of Safety and Professional Services. Q: We would like to close our facility, how do we notify the Board? A: For Wholesale Distributors, Drug or Device Manufacturers and Pharmacy (out of state only) Please submit a letter to the board requesting closure. Indicate your facility name license number and reason for closure. For Pharmacy (In state) you must file a Pharmacy Closing Affidavit available on the Department website at dsps.wi.gov Go to "Application/Forms” link posted under your profession. #2661 (Rev. 9/11) Ch. 440.06(3), Stats. Committed to Equal Opportunity in Employment and Licensing American LegalNet, Inc. www.FormsWorkFlow.com