Get Cdph8679

Filling out the Cdph8679 online is a crucial step for individuals or organizations seeking a home medical device retailer license in California. This guide provides comprehensive, step-by-step instructions for completing the form accurately and efficiently.

Follow the steps to complete the Cdph8679 application online.

1. Click the ‘Get Form’ button to access the Cdph8679 application form and open it in your preferred online editor.
2. Begin by providing the legal name of your firm in the designated field. Ensure accuracy as this name will be used for official purposes.
3. If applicable, enter any fictitious or 'doing business as' (DBA) names in the space provided. If you have more than one DBA, attach a separate sheet.
4. Fill in the facility address, including street number, city, state, and zip code. Make sure all details are complete and correctly presented.
5. Provide your mailing address if it differs from the facility address. Include the full address, city, state, and zip code.
6. Enter the name and title of the facility operator responsible for managing operations at the location.
7. Input the facility's daytime telephone number, along with the FAX number for official communications.
8. Include a 24-hour emergency telephone number that can be contacted in case of emergencies.
9. Provide the facility's email address in the designated space for routine correspondence.
10. List the correspondent's name and title who can be contacted about this application, along with their daytime telephone and FAX numbers.
11. Indicate if the facility is located outside the United States. If so, provide the country name.
12. If applicable, enter the website URL for your business, ensuring it is accurate and operational.
13. Select the type of ownership by marking the appropriate options provided a single choice.
14. If your business is incorporated, provide the corporate name and the state of incorporation.
15. List the names and titles of the business owners or officers. If additional space is needed, attach a separate list.
16. Select the type of application you are submitting, such as new application or renewal, by marking the applicable box.
17. Specify the type of business you will conduct at this facility and provide the business license, FEIN, and seller's permit number as required.
18. Indicate the products you will be selling by checking all applicable boxes, ensuring compliance with regulations.
19. If your facility will sell or rent legend devices, indicate yes or no, and provide details as required.
20. Answer whether you have a Medi-Cal or Medicare provider number, indicating pending status if applicable.
21. Select one payment code that corresponds to your application fee type, marking only one code before submission.
22. Provide the required original signature, printed name, title, and date at the bottom of the form.
23. Review the completed form for accuracy, then save your changes, download a copy, print it for records, or share it as needed.

Complete your Cdph8679 application online today to ensure a smooth licensing process.