Change Of Permit Pharmacy Hospital Clinic Non Resident Pharmacy Licensed Correctional Facility (Instructions) {17M-70}

17M-70, CHANGE OF PERMIT APPLICATION INSTRUCTIONS (Licensees Only) Pharmacy, Nonresident Pharmacy, Hospital Pharmacy, Sterile Compounding Pharmacy, Clinic, Correctional Facility, A Change of Permit Application must be submitted to the Board within 30 days when one of the following changes occurs: • Change of Tradestyle Name or Corporate Name (Does not include a change of ownership.) • Address Change: Includes change of street name or number made by the United States Postal Service, government entity, suite number, etc. (Does NOT include a physical change of location.) • Change of Officer(s), Partner(s), Member(s), or Owner(s) • Change of Administrator/Warden • Transfer an Assignment of Beneficial Interest of 10% to 49% All of the required forms identified in the application instructions must be submitted with the application. If the facility is owned by a corporation, at least one officer must sign; if owned by a partnership, one partner must sign; if individual ownership, the majority owner must sign; or a limited liability company, one member must sign. Allow the Board 30 days for processing the application. The designated person reflected on the application will be advised if additional information is necessary. www.FormsWorkflow.com