Form S-320, Supplemental Application: LLC Ownership Instructions
This form contains 70 fields organized into 10 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Applicant Information | ||
| Pharmacy/Facility Name | Text |
Provide the full legal name of the pharmacy or facility, including any 'Doing Business As' (DBA) name if applicable.
|
| Phone Number | Text |
Enter the primary telephone number for the pharmacy or facility.
|
| Pharmacy/Facility Address | Text |
Enter the complete street address of the pharmacy or facility.
|
| City | Text |
Provide the city where the pharmacy or facility is located.
|
| State | Text |
Enter the state where the pharmacy or facility is located.
|
| Zip Code | Text |
Provide the zip code for the pharmacy or facility's address.
|
| County | Text |
Enter the county where the pharmacy or facility is located.
|
| Date Signed | ||
| Date Signed | Date |
Please provide the date when the document was signed.
|
| First LLC Member | ||
| Member Name 1 | Text |
Please enter the full legal name of the first LLC member.
|
| Member 1 Title | Text |
Please enter the title or position of the first LLC member.
|
| Member 1 Address of Record | Text |
Please enter the complete street address of record for the first LLC member.
|
| Member 1 Ownership Percentage | Number |
Please enter the percentage of ownership the first LLC member holds in the LLC.
|
| Member 1 City | Text |
Please enter the city for the first LLC member's address of record.
|
| Member 1 State | Text |
Please enter the state for the first LLC member's address of record.
|
| Member 1 Zip Code | Text |
Please enter the zip code for the first LLC member's address of record.
|
| Member 1 County | Text |
Please enter the county for the first LLC member's address of record.
|
| Member 1 KS Pharmacy License Number and Type | Text |
Please enter the Kansas Board of Pharmacy License Number and Type for the first LLC member, if applicable.
|
| General | ||
| SIGNATURE | Signature | |
| LLC Information | ||
| LLC Name | Text |
Enter the full legal name of the Limited Liability Company.
|
| LLC Address | Text |
Provide the street address of the Limited Liability Company.
|
| LLC City | Text |
Enter the city where the Limited Liability Company is located.
|
| LLC State | Text |
Enter the state where the Limited Liability Company is located.
|
| LLC Zip Code | Text |
Enter the postal zip code for the Limited Liability Company's address.
|
| LLC County | Text |
Enter the county where the Limited Liability Company is located.
|
| FEIN | Text |
Enter the Federal Employer Identification Number (FEIN) for the Limited Liability Company.
|
| LLC Phone Number | Text |
Enter the primary phone number for the Limited Liability Company.
|
| LLC Manager Information | ||
| LLC Manager Name | Text |
Provide the full legal name of the LLC manager.
|
| Manager Address of Record | Text |
Enter the street address of record for the LLC manager.
|
| Manager Ownership Percentage | Number |
Enter the percentage of ownership held by this LLC manager.
|
| Manager City | Text |
Enter the city for the LLC manager's address of record.
|
| Manager State | Text |
Enter the state for the LLC manager's address of record.
|
| Manager Zip Code | Text |
Enter the zip code for the LLC manager's address of record.
|
| Manager County | Text |
Enter the county for the LLC manager's address of record.
|
| Manager Pharmacy License Number & Type | Text |
Provide the Kansas Board of Pharmacy License Number and Type for the LLC manager, if applicable.
|
| Member 3 Information | ||
| Member 3 Name | Text |
Enter the full name of Member 3.
|
| Member 3 Title | Text |
Enter the professional or organizational title of Member 3.
|
| Member 3 Address of Record | Text |
Enter the physical street address of record for Member 3.
|
| Member 3 Ownership Percentage | Number |
Enter the percentage of ownership Member 3 holds in the LLC.
|
| Member 3 City | Text |
Enter the city for Member 3's address of record.
|
| Member 3 State | Text |
Enter the state for Member 3's address of record.
|
| Member 3 Zip Code | Text |
Enter the zip code for Member 3's address of record.
|
| Member 3 County | Text |
Enter the county for Member 3's address of record.
|
| Member 3 Pharmacy License Number and Type | Text |
Enter Member 3's Kansas Board of Pharmacy license number and type, if applicable.
|
| Member 4 Information | ||
| Member Name | Text |
Enter the full name of Member 4.
|
| Member Title | Text |
Provide the professional title or role of Member 4 within the LLC.
|
| Address of Record | Text |
Enter the primary mailing address of record for Member 4.
|
| Percent Ownership of LLC | Number |
Enter the percentage of ownership Member 4 holds in the LLC.
|
| City | Text |
Enter the city for Member 4's address of record.
|
| State | Text |
Enter the state for Member 4's address of record.
|
| Zip Code | Text |
Enter the zip code for Member 4's address of record.
|
| County | Text |
Enter the county for Member 4's address of record.
|
| Kansas Board of Pharmacy License | Text |
Enter Member 4's Kansas Board of Pharmacy license number and type, if applicable.
|
| Member 5 Information | ||
| Member Name | Text |
Please enter the full name of Member 5.
|
| Title | Text |
Please enter the job title of Member 5.
|
| Address of Record | Text |
Please enter the complete address of record for Member 5.
|
| Ownership Percentage of LLC | Number |
Please enter the percentage of LLC ownership held by Member 5.
|
| City | Text |
Please enter the city of the address of record for Member 5.
|
| State | Text |
Please enter the state of the address of record for Member 5.
|
| Zip Code | Text |
Please enter the zip code of the address of record for Member 5.
|
| County | Text |
Please enter the county of the address of record for Member 5.
|
| Pharmacy License Number and Type | Text |
Please enter Member 5's Kansas Board of Pharmacy License Number and Type, if applicable.
|
| Second LLC Member | ||
| Member Name 2 | Text |
Enter the full name of the second LLC member.
|
| Member 2 Title | Text |
Provide the professional title of the second LLC member.
|
| Member 2 Address of Record | Text |
Enter the complete physical address of record for the second LLC member.
|
| Member 2 Ownership Percentage | Number |
Enter the percentage of ownership the second LLC member holds in the LLC.
|
| Member 2 City | Text |
Enter the city of the second LLC member's address of record.
|
| Member 2 State | Text |
Enter the state of the second LLC member's address of record.
|
| Member 2 Zip Code | Text |
Enter the zip code of the second LLC member's address of record.
|
| Member 2 County | Text |
Enter the county of the second LLC member's address of record.
|
| Member 2 Pharmacy License Number and Type | Text |
Provide the Kansas Board of Pharmacy license number and type for the second LLC member, if applicable.
|