Fillable FORM A. SOLE PROPRIETOR OR PARTNERSHIP OWNERSHIP INFORMATION: (Oklahoma)

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FORM A. SOLE PROPRIETOR OR PARTNERSHIP OWNERSHIP INFORMATION: (Oklahoma)

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Oklahoma State Board of Pharmacy Page 1 of 2 Aug-21
FORM A. SOLE PROPRIETOR OR PARTNERSHIP OWNERSHIP INFORMATION
A. APPLICANT. (PLEASE TYPE OR PRINT CLEARLY)
PHARMACY OR FACILITY NAME and DBA NAME APPLYING FOR LICENSE
ADDRESS OF PHARMACY OR FACILITY (include city/town name, state/province/county, ZIP and Country)
B. INDIVIDUAL/SOLE PROPRIETOR OWNER. Provide the following information if the applicant is owned by a sole proprietor.
NAME OF INDIVIDUAL/SOLE PROPRIETOR
ADDRESS OF INDIVIDUAL/SOLE PROPRIETOR
(include city/town name, state/province/county, ZIP and Country)
FEDERAL EMPLOYER ID NUMBER (FEIN)
LICENSED OK PHARMACIST? ___ Yes ___ No IF YES, OK DPH LICENSE #
C. PARTNER
SHIP OWNER (P, LP or LLP).
Provide the following information if the applicant is owned by a partnership.
NAME OF PARTNERSHIP
ADDRESS OF PARTNERSHIP (include city/town name, state/province/county, and ZIP) COUNTRY OF FORMATION
FEDERAL EMPLOYER ID NUMBER (FEIN) OF PARTNERSHIP
D. PARTNE
RS.
You must provide the following information for each partner of the partnership listed in Section C above. If additional
space is needed, please attach a separate sheet. Total partner percentages must equal 100%.
PARTNER NAME 1
ADDRESS OF RECORD (include city/town name, state/province/county, ZIP and Country)
%OWNERSHIP
LICENSED OK PHARMACIST? ___ Yes ___ No IF YES, OK DPH LICENSE #
PARTNER NAME 2
ADDRESS OF RECORD (include city/town name, state/province/county, ZIP and Country) %OWNERSHIP
LICENSED OK PHARMACIST? ___ Yes ___ No IF YES, OK DPH LICENSE #
OKLAHOMA STATE BOARD OF PHARMACY
2920 N Lincoln Blvd, Ste A, Oklahoma City, OK 73105
Phone: (405) 521-3815 / Fax: (405) 521-3758
www.pharmacy.ok.gov / e-mail: pharmacy@pharmacy.ok.gov
IMPORTANT: If any of the partne
r
s listed below is an LLC, Partnership or a Corporation, a separate, additional ownership
form
(
e.
g
. Form A
,
B1
,
B2 or C
)
must also be com
p
leted for that
p
artne
r
.
Information may be typed in before printing. Click the Reset button to clear the form.
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Oklahoma State Board of Pharmacy Page 2 of 2 Aug-21
State of ______________________)
County of _____________________)
Subscribed and sworn to or affirmed before me
this ______ day of _______________ , 20
_____ .
________________________________
Notary Public
FORM A. SOLE PROPRIETOR OR PARTNERSHIP OWNERSHIP INFORMATION – continued
PARTNER NAME 3
ADDRESS OF RECORD (include city/town name, state/province/county, ZIP and Country) %OWNERSHIP
LICENSED OK PHARMACIST? ___ Yes ___ No IF YES, OK DPH LICENSE #
PARTNER NAME 4
ADDRESS OF RECORD (include city/town name, state/province/county, ZIP and Country) %OWNERSHIP
LICENSED OK PHARMACIST? ___ Yes ___ No IF YES, OK DPH LICENSE #
PARTNER NAME 5
ADDRESS OF RECORD (include city/town name, state/province/county, ZIP and Country) %OWNERSHIP
LICENSED OK PHARMACIST? ___ Yes ___ No IF YES, OK DPH LICENSE #
I swear and affirm under penalty of perjury pursuant to Title 21 O.S. 491 and/or discipline by the Board of
Pharmacy under the pharmacy laws and rules of the State of Oklahoma that all information I have supplied herein
is true and complete
.
THIS SIGNATURE MUST BE NOTARIZED:
Printed Name & Title of Owner or Partner
Signature of Owner or Partner
THE FOLL
OWING MUST BE SUBMITTED WITH THIS DOCUMENT:
1. Oklahoma State Board of Pharmacy Application & Fee (PAID ONLINE ONLY)
2. If Partnership –
STATEMENT OF PARTNERSHIP AUTHORITY
3. If Limited Partnership –
CERTIFICATE OF LIMITED PARTNERSHIP
4. If Limited Liability Partnership –
STATEMENT OF QUALIFICATION
5. Additional Ownership Form(s) for Partners (if applicable - see Sect D)
NOTE: A copy of the written Partnership Agreement must be made available to the Board if the Board so requests.
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FORM A. SOLE PROPRIETOR OR PARTNERSHIP OWNERSHIP INFORMATION: (Oklahoma)

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Completed 3 March 2022

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