California > Statewide > Board Of Pharmacy
Application For A Designated Representative License 17A-E - California
| Application For A Designated Representative License Form. This is a California form and can be used in Board Of Pharmacy Statewide . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
California State Board of Pharmacy 1625 N. Market Blvd, Suite N219, Sacramento, CA 95834 Phone (916) 574-7900 Fax (916) 574-8618 www.pharmacy.ca.gov STATE AND CONSUMERS AFFAIRS AGENCY DEPARTMENT OF CONSUMER AFFAIRS GOVERNOR EDMUND G. BROWN JR. MILITARY SPOUSES/ PARTNERS - Check here if you are relocating to CA as a result of your spouse's/partner's active duty military service. APPLICATION FOR A DESIGNATED REPRESENTATIVE* LICENSE Print or type Name: Last First Middle Former **Address of record: Number Street TAPE A PHOTOGRAPH TAKEN WITHIN Zip Code City State 60 DAYS OF THE FILING OF THIS APPLICATION Residence Address: (if different from above) Number Street City State Zip Code NO POLAROID OR SCANNED IMAGES Home telephone number: ( ) Email address: EDUCATION Work telephone number: ( ) Fax Number: ( ) Date of Birth Social Security Number *** Name of high school attended Graduate from high school? Yes Date: Name that appears on diploma or GED certificate: PHARMACIST EXAM Location of school (city & state) GED Date: Are you eligible to take the California pharmacist licensure exam? If "yes," provide the date you applied: Yes No Name applied under: *Note: Under California law, the name used to describe any individual who is in charge of any wholesale drug premises (in California or elsewhere) will change on January 1, 2006, from the former name, exemptee, to designated representative. For conventional use, the board will refer to such an individual as a designated representative throughout this application. ** Once you are licensed with the board the address of record you enter on this application is considered public information pursuant to the Information Practices Act (Civil Code section 1798 et seq.) and the Public Records Act (Government Code section 6250 et seq.) and will be placed on the Internet upon licensure. If you do not wish your residence address to be available to the public, you may provide a post office box number or a personal mail box (PMB). However, if your address of record is a box number you must also provide your residence address as an alternate address that will not be available to the public. DO NOT WRITE BELOW THIS LINE Live Scan Photo Exp Aff FP Clearance Training cert Hours verified Enforce Certification No. Date Issued Application fee no. Amount Date Cashiered 17A-E (Rev 12/12) American LegalNet, Inc. www.FormsWorkFlow.com You must provide a written explanation for all affirmative answers. Failure to do so may result in this application being deemed incomplete. 1. Do you currently engage, or have you been engaged in the past two years, in the illegal use of controlled substances? If "yes," are you currently participating in a supervised rehabilitation program or professional assistance program which monitors you in order to assure that you are not engaging in the illegal use of controlled dangerous substances? Attach a statement of explanation. 2. Has disciplinary action ever been taken against your pharmacist license, intern permit or exemption certificate in this state or any other state? If "yes," attach a statement of explanation to include circumstances, type of action, date of action and type of license, registration or permit involved. Yes No Yes No 3. Have you ever had an application for a pharmacist license, intern permit or exemption Yes certificate denied in this state or any other state? If "yes," attach a statement of explanation to include circumstances, type of action, date of action and type of license, registration or permit involved. 4. Have you ever had a pharmacy permit, or any professional or vocational license, certification or registration denied or disciplined by a governmental authority in this state or any other state? If "yes," provide the name of company, type of permit, type of action, year of action and state. 5. Have you ever been convicted of or pled no contest to a violation of any law of a foreign country, the United States or any state laws or local ordinances? You must include all misdemeanor and felony convictions, regardless of the age of the conviction, including those which have been set aside under Penal Code sections 1000 or 1203.4. Traffic violations of $500 or less need not be reported. If "yes," attach an explanation including the type of violation, the date, circumstances, location and the complete penalty received. 6. Are you currently or have you previously been listed as a corporate officer, partner, owner, manager, member, administrator or medical director on a permit to conduct a pharmacy, wholesaler, or any other entity licensed in this state or any other state? If yes, provide company name, type of permit, permit number and state where licensed. 7. Do you have, or have you had in the last 5 years, any direct or indirect beneficial interest in any other premises licensed by the Board of Pharmacy? 8. Have you ever been in violation of any provisions of pharmacy law? Yes 9. Are you currently or have you previously been associated in business with any person, partnership, corporation or other entity, or shared a financial or community property interest with any person whose permit or any professional or vocational license was denied, suspended, revoked, or placed on probation or other disciplinary action taken by this or any other governmental authority in this state or any other state by a federal regulatory agency? Yes Yes No No Yes No Yes No Yes No No No 17A-E (Rev 12/12) American LegalNet, Inc. www.FormsWorkFlow.com Please read carefully and sign below. I understand that falsification of the information on this form may constitute grounds for denial or revocation of the license. I hereby certify under penalty of perjury under the laws of the State of California to the truth and accuracy of all statements, answers and representations made in this application, including all supplementary statements. I also certify that I personally completed this application and have read and understand the instructions attached to this application. Signature of applicant (in full--no initials) Date signed ***Disclosure of your social security number is mandatory. Business and Professions Code section 30 and Public Law 94-455 (42 USCA 405(c)(2)(C) authorize collection of your social security number. Your social security number will be used exclusively for tax enforcement purposes of compliance with any judgement or order for family support in accordance with section 11350.6 of the Welfare and Institutions Code. If you
|
|||||||
