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Designated Representative Experience Declaration 17A-E2 - California
| Designated Representative Experience Declaration Form. This is a California form and can be used in Board Of Pharmacy Statewide . |
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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 CONSUMER SERVICES AGENCY DEPARTMENT OF CONSUMER AFFAIRS ARNOLD SCHWARZENEGGER, GOVERNOR DESIGNATED REPRESENTATIVE EXPERIENCE DECLARATION TO BE COMPLETED BY APPLICANT (Please print or type) Name of Applicant Last First Middle Former Residence Address Number and Street City State Zip Code Home telephone number Work telephone number (Please print or type) TO BE COMPLETED BY THE PERSON HAVING DIRECT KNOWLEDGE OF APPLICANT'S EXPERIENCE (Name of Applicant) was employed for at least one year of paid experience related to the distribution or disposition of dangerous drugs or dangerous devices. from (month/day/year) to (month/day/year) Number of years DO NOT state "current, present or still employed" (use exact dates) NAME AND ADDRESS OF EMPLOYER Name of Business Board of Pharmacy License Number Address Number and Street City State Zip Code Name of Person Having Direct Knowledge (please print) Telephone Number I declare under penalty of perjury under the laws of the State of California that all statements given herein are true and correct. Signature of Person Having Direct Knowledge of Applicant's Work Experience Position Date 17A-E2 (12/04) American LegalNet, Inc. www.FormsWorkflow.com
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