California > Statewide > Board Of Pharmacy
License Verification 17M-17 - California
| License Verification 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 LICENSE VERIFICATION INSTRUCTIONS: This form is to be completed by the licensing authority in each state where you are licensed. The form must be completed even if the license is no longer current or active. Please return the state verified form with your application. TO BE COMPLETED BY APPLICANT (Please print or type) Name of Applicant Address (Street and Number) Title of License City License Number Telephone Number ( ) State Issue Date Zip Code Exp. Date TO BE COMPLETED BY STATE BOARD OFFICE VERIFYING LICENSURE The person listed above has applied for a wholesale license in California. Before further consideration is given this application, we would appreciate your assistance in completing the information requested below. Upon completion of this form, please return it to the applicant for submission with the application. LICENSURE VERIFICATION PROVIDED BY THE STATE OF ____________________________________ Name Type of License Issued: License Status: Active Inactive Other If other, please explain: ______________________________________ No Date License Issued License Number Exp. Date of License Has the licensee been found guilty of any violation for which disciplinary action was taken? Yes If disciplinary action has been taken against this licensee, please provide this office with all the available documentation regarding the action. Signature Board Seal Title Date 17M-17 (1/05) American LegalNet, Inc. www.FormsWorkflow.com
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