California > Statewide > Board Of Pharmacy
Individual Personal Affidavit 17A-27 - California
| Individual Personal Affidavit 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 CONSUMERS AFFAIRS AGENCY DEPARTMENT OF CONSUMER AFFAIRS GOVERNOR EDMUND G. BROWN JR. INDIVIDUAL PERSONAL AFFIDAVIT Please print or type Full name: Last All blanks must be completed; if not applicable enter N/A First Middle Previous name(s) include maiden name, also known as (AKA's), "aliases": Attach a photograph taken within 60 days of the filing of this affidavit Residence address: Number and Street City State Zip Code Date of birth (month/day/year) Place of birth (city, state, country) Driver's license no & state issued in *Social Security number NO POLAROID Home telephone: Current work telephone: Name of applicant premises: Address of applicant premises: Premises telephone: Number and Street City State Zip Code I am (Check all that apply) Sole owner Officer Partner Director General partner Stockholder ______% Last First Financier/lender Member (LLC only) Middle Other - Specify: Spouse's name (Include alias or maiden) Spouse's social security number Spouse's Date of Birth Will your spouse work in any capacity under the permit? Yes No Do you have, or have you had, any direct or indirect beneficial interest in any other premises licensed by any board of pharmacy? Include sites licensed in states other than California. Yes No If yes, list current direct or indirect beneficial interests (use an additional sheet if necessary). Name Name Name Address Address Address Permit Number Permit Number Permit Number If yes, list past direct or indirect beneficial interests during the last five years (use additional sheet if necessary): Name Address Permit Number Name Address Permit Number 17A-27 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Have you -- as an owner, shareholder, officer, member, director or partner -- been involved with a pharmacy, drug wholesaler, medical device retailer, hypodermic permit or out-of-state distributor whose license has been disciplined or an offer in compromise accepted or rejected by a state board of pharmacy or federal regulatory agency? Have you as an individual held a pharmacist license, pharmacy technician registration or exemption certificate that has been disciplined or an offer in compromise accepted or rejected by a state board of pharmacy or federal regulatory agency? Also describe if any of the above actions have occurred with your spouse or palimony partner, or an associate with whom you have shared any ownership interest. Describe the event, regulatory agency involved and date for each incident. (If yes, explain. Use additional sheets if necessary) Yes No Have you as an individual ever been issued any professional or vocational license such as a medical doctor, attorney, dentist, contractor, etc. that has been disciplined by a state regulatory board? (If yes, explain.) Yes No Current and past employment for at least the past five years. (Use additional sheets if necessary). From (mo/yr) To (mo/yr) Type of Work Firm name and city 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 authorize the Board of Pharmacy, or any of its authorized personnel, to examine and secure copies of financial records consisting of signature cards, checking and savings accounts, note and loan documents, deposit and withdrawal records, and escrow documents of my financial institution(s) or any financial records established in connection with this business. This authorization to examine records at any financial institution may be at any time. I also authorize the Board of Pharmacy, or any of its authorized personnel, to examine and secure copies of any business records or documents established in connection with this business including, but not limited to those on file with my bookkeeper. 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 the foregoing individual personal affidavit, including all supplementary statements and I personally completed this personal affidavit. Applicant Signature Place Title Attest (Notary Public Date Disclosure of your social security number is mandatory. Section 30 of the Business and Professions Code 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, or for verification of examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state. If you fail to disclose your social security number, your application for initial or renewal license will not be processed AND you will be reported to the Franchise Tax Board, which may assess a $100 penalty against you." NOTICE: Effective July 1, 2012, the State Board of Equalization and the Franchise Tax Board may share individual taxpayer information with the board. You are obligated to pay your state tax obligation. This application may be denied or your license may be suspended if the state tax obligation is not paid. American LegalNet, Inc. 17A-27 (1/12) Page 2 of 2 www.FormsWorkFlow.com
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