California > Statewide > Board Of Pharmacy
Designated Representative Training Declaration 17A-E3 - California
| Designated Representative Training 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* TRAINING DECLARATION TO BE COMPLETED BY APPLICANT (Please print or type) Name of Applicant Residence Address Home telephone number Last First City Middle State Former Zip Code Number and Street Work telephone number TO BE COMPLETED BY THE PERSON HAVING DIRECT KNOWLEDGE OF APPLICANT'S TRAINING The individual applying for certification as a designated representative in California has completed training required by Section 4053 of the California Business and Professions Code that addressed, at a minimum: · Knowledge and understanding of California and federal laws regarding the distribution of dangerous drugs and dangerous devices; · Knowledge and understanding of California and federal laws regarding the distribution of controlled substances; · Knowledge and understanding of United States Pharmacopoeia standards for the safe storage and handling of drugs; · Knowledge and understanding of quality control systems; and · Knowledge and understanding of prescription terminology, abbreviations, dosages and format. THIS TRAINING WAS PROVIDED BY (Please print or type) Name of company, school or individual providing the training Name of Person Having Direct Knowledge of Training Address City State Zip Code Telephone Number From to (month/day/year) (month/day/year) DO NOT use "current, present or still employed" (use exact dates) Number of hours I declare under penalty of perjury under the laws of the State of California that all statements given herein are true and correct. Position Date Signature of Person Having Direct Knowledge of Applicant's Training *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. 17A-E3 (1/05) American LegalNet, Inc. www.FormsWorkflow.com
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