Clinic License Application {17A-68}

17A-68 - CALIFORNIA WHOLESALER LICENSE APPLICATION. This form is used to apply for a license from the California State Board of Pharmacy to operate as a wholesaler of pharmaceuticals and medical products. The form is also utilized for specific requests such as obtaining a temporary license, reporting a change of ownership or location, and identifying the Designated Representative-in-Charge (DRIC) responsible for compliance with laws. It collects detailed information about the applicant, ownership structure, business operations, disciplinary history, and supporting documentation like leases or deeds. Complete the entire application and submit with original signatures. Do Not Leave Blanks: If an item or question is not applicable, indicate N/A. Doing Business As (DBA): If using a DBA, submit a completed Fictitious Business Name Statement that has been certified by the Office of the County Clerk in the county in which it was filed. www.FormsWorkflow.com