Nonresident Wholesaler License Application {17A-65 }

17A-65 - NONRESIDENT WHOLESALER LICENSE APPLICATION. This form is used by businesses located outside of California to apply for a license to distribute pharmaceutical products within the state. It includes sections for applicant information, type of application (new, change of ownership, or location), ownership structure, contact information, designated representative-in-charge (DRIC), business operations, officer and ownership details, disciplinary history, and background information about other licenses. Applicants must provide supporting documents, attest to the truth of the application, and comply with California laws and regulations. The form also allows for optional authorization to disclose application status to third parties. The information will be used to determine qualifications for licensure under the California Pharmacy Law. The official responsible for information maintenance is the Executive Officer at the California State Board of Pharmacy. The information may be transferred to another governmental agency, such as a law enforcement agency, if necessary to perform its duties. Each individual has the right to review the files or records maintained on him/her by the Board of Pharmacy, unless the records are identified as confidential and exempted by Civil Code section 1798.38. www.FormsWorkflow.com