California > Statewide > Board Of Pharmacy
Personal Background Affidavit 17A-37 - California
| Personal Background 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. PERSONAL BACKGROUND AFFIDAVIT All blanks must be completed; if not applicable enter "N/A". Failure to furnish a complete explanation, or any omissions, will delay the processing of your application. If fingerprints will be taken outside of California, you must submit one set of two completed fingerprint cards and the fingerprint processing fee of $51.00. If prints will be taken in California, you must submit a copy of the Request for Live Scan Service Form verifying that fingerprints have been scanned and all applicable fees have been paid. Please print or type Full name: Address: Last First Number and Street *Social Security number: City Middle State Telephone Number: ( ) Zip Date of birth: (MM/DD/YY) Previous name(s) include maiden name; also known as (AKA's); "aliases": Applicant telephone number: Name of applicant (business name): Address of applicant: Number and Street City State Zip My position with the applicant is: Sole owner Other 1. Partner please specify (Check all that apply) Officer Stockholder Member Are you currently, or have you in the previous five years, been a manager, administrator, owner, member, officer, director, associate, or partner of any partnership, corporation, firm, or association whose application for a license has been denied or whose license has been revoked, suspended, or been placed on probation in California or any other state? Yes No If the answer is "yes," please provide the following information for each action taken. Please include cancelled permits. (Use additional sheets if necessary.) Company Name: Type of License: License #: State: Position Held: Type of Action: Year of Action: 17A-37 (Rev. 1/12) Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Company Name: Type of License: License #: State: Position Held: Type of Action: Year of Action: Company Name: Type of License: License #: State: Position Held: Type of Action: Year of Action: 2. Have you ever had a professional or vocational license denied, suspended, revoked, voluntarily surrendered, placed on probation or other disciplinary action taken by this or any other governmental authority in this state, any other state or by a federal regulatory agency? Yes No If the answer is "yes," please provide company name, permit type, action, year of action and state. (Use additional sheets if necessary.) Type of License: Type of License: Type of License: License #: License #: License #: Type of Action: Type of Action: Type of Action: Year of Action: Year of Action: Year of Action: State: State: State: 3. Have you ever been in violation of any provisions of California pharmacy law, including regulations? Yes No If "yes," please list each type of violation, license type, type of action, year of action and state. (Use additional sheets if necessary.) Type of License: Type of Action: License #: State: Year of Action: Type of License: Type of Action: License #: State: Year of Action: Type of License: Type of Action: License #: State: Year of Action: Type of License: Type of Action: License #: State: Year of Action: 17A-37 (1/12) Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 4. Have you ever been convicted of, or pled no contest to, a violation of any law of a foreign country, the United States or of any state or local ordinances? You must include all misdemeanor and felony convictions, regardless of the age of the conviction, including those which have been set aside and/or dismissed under Penal Code sections 1000 or 1203.4. (Traffic violations of $500 or less need not be reported.) If "yes," please attach the relevant arrest and court documents. Yes No 5. Do you currently engage in, or have you been engaged in the past two years in, the illegal use of controlled substances? Yes No If " yes," are you currently participating in a supervised rehabilitation program or professional assistance program which monitors you in order to assure that you are not engaging in the illegal use of controlled substances? Please attach a statement of explanation. 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 certify under penalty of perjury under the laws of the State of California that all statements, answers and representations made in the foregoing personal background affidavit, including all supplementary statements are true and accurate and that I personally completed this personal background affidavit. Signature Print Name Date Title *Disclosure of your social security number is mandatory. Business and Professions Code section 30 and Public Law 94455 (42 USC 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. 17A-37 (1/12) Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com
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