Get Ca 17a-12 2022-2026

This guide provides a detailed walkthrough for users on how to fill out the CA 17A-12, the pharmacy change of permit application, online. It aims to simplify the process by breaking down each section and field, thus ensuring accurate and efficient completion.

Follow the steps to successfully complete the CA 17A-12 online.

1. Click the ‘Get Form’ button to obtain the CA 17A-12 form and open it in the editor.
2. Review Section A: Identify the type of changes you are applying for and select the appropriate checkbox. Remember to note the corresponding processing fees.
3. In Section B, provide the licensee information including the name as it appears on the current license, license type, number, and contact information.
4. Proceed to Section C to identify your contact person and authorized signer. This person will be the main point of communication regarding your application.
5. If you are making an address change, fill out Section D, ensuring you provide the effective date of the change and submit one of the required supporting documents.
6. For a trade style name change, complete Section E and submit the necessary documentation to validate the name change.
7. Complete Section F if you are changing the corporate name, ensuring to include supporting documents specified in this section.
8. In Section G, provide details when adding or removing an administrator or consulting pharmacist, along with required supporting documentation as indicated.
9. Section H captures information about changes involving officers, directors, or partners. Be thorough in ensuring accurate report of changes.
10. If applicable, fill out Section I for transferring an assignment of beneficial interest, adhering to documentation guidelines.
11. In Section J, affix required signatures, ensuring accuracy and compliance with the declaration statement.
12. Finally, if fingerprints are required, refer to Section K and follow the instructions for completing the fingerprint process.
13. After completing the form, save your changes. You can then download, print, or share the CA 17A-12 form as necessary.

Get started with your pharmacy change of permit application by filling out the CA 17A-12 online today.