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Change Of Pharmacist-In-Charge 17A-14 - California
| Change Of Pharmacist-In-Charge Form. This is a California form and can be used in Board Of Pharmacy Statewide . |
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California State Board of Pharmacy STATE AND CONSUMER S S AGENCY 1625 N. Market Blvd, Suite N219, Sacramento, CA 95834 Phone (916) 574-7900 Fax (916) 574-8618 www.pharmacy.ca.gov DEPARTMENT OF CONSUMER AFFAIRS GOVERNOR EDMUND G. BROWN JR. CHANGE OF PHARMACIST-IN-CHARGE Both the owner of a pharmacy and the pharmacist-in-charge are required by California law to notify the Board of Pharmacy within 30 days after the termination of the pharmacist-in-charge. Failure to make this notification to the board may result in disciplinary action. To properly notify the board of a change in pharmacist-in-charge, the following items must be submitted: · · · Completed Change of Pharmacist-in-Charge form $100 fee (excluding clinics, non-resident pharmacies and government owned facilities) Certification of Personnel for NEW pharmacist-in-charge only ALL SECTIONS MUST BE COMPLETED Telephone Street Cit y State (Please print or type) Name of pharmacy: Pharmacy permit number Zip Address of pharmacy: List below the name, license number and address of the new pharmacist-in-charge: Name Pharmacist license number Zip Home address Effective date Street Cit y State List below the name, license number and address of the pharmacist-in-charge being replaced: Name Pharmacist license number Zip Home address Date of disassociation Street Cit y State I 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 the foregoing. Signature of owner, partner or corporate officer Signature of new pharmacist-in-charge Signature of pharmacist-in-charge being replaced (if available) 17A-14 (Rev. 1/08) Typed or printed name and title Date Date Cashier # _______________________ Date Date ___________________________ Amount ________________________ 17A-14 Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com
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