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Designated Representative Requirements And Application (Instructions) 17M-27 - California
| Designated Representative Requirements And Application (Instructions) 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 SERVICES AGENCY DEPARTMENT OF CONSUMER AFFAIRS GOVERNOR EDMUND G. BROWN JR. DESIGNATED REPRESENTATIVE* REQUIREMENTS AND APPLICATION A designated representative* is an individual who performs clerical, inventory control, housekeeping, delivery, maintenance, or similar functions related to the distribution or dispensing of dangerous drugs or dangerous devices. To work as a designated representative, you must possess and keep a current certificate as a designated representative. Active Duty Military -- Spouses or Partners Receive Expedited Review The board is required to expedite the licensure process for an applicant whose spouse or partner is an active duty member of the U.S. Armed Forces and meets other criteria. (Business and Professions Code section 115.5.) If you would like to be considered for this expedited review and process, please provide the following required documentation. 1. Are you married to, or in a domestic partnership or other legal union with, an active duty member of the Armed Forces of the United States who is assigned to a duty station in California under official active duty military orders? If "yes," please attach a copy of the marriage certificate or certified declaration/registration of domestic partnership filed with the Secretary of State AND military orders establishing duty station in California. For other forms of "legal union" not recognized by California, you may submit other documentary evidence of legal union issued by the State that recognizes your legal union for consideration by the board in meeting this requirement. 2. Do you hold a current license in another state, district, or territory of the United States in the profession or vocation for which you seek licensure from the board? If "yes," please attach a copy of the current license in another state, district, or territory of the United States. DESIGNATED REPRESENTATIVE CERTIFICATION REQUIREMENTS An individual applying to become a designated representative shall meet the following requirements: Be a high school graduate or possess a general education development equivalent, Have a minimum of one year of paid work experience related to the distribution or dispensing of dangerous drugs or dangerous devices or meet all of the prerequisites to take the examination required for licensure as a pharmacist by the board, and Complete a training program that, at a minimum, addresses each of the following subjects: (A) Knowledge and understanding of California and federal law relating to the distribution of dangerous drugs and dangerous devices. (B) Knowledge and understanding of California and federal law relating to the distribution of controlled substances. (C) Knowledge and understanding of quality control systems. American LegalNet, Inc. www.FormsWorkFlow.com (D) Knowledge and understanding of the United States Pharmacopoeia standards relating to the safe storage and handling of drugs. (E) Knowledge and understanding of prescription terminology, abbreviations, dosages and format. HOW TO APPLY TO BECOME A DESIGNATED REPRESENTATIVE Your application must include: A non-refundable application fee of $255. A completed Application for A Designated Representative License (17A-E), with all questions answered. You must sign this form and attach a photograph, scanned photos are not acceptable. A completed Designated Representative Experience Declaration (17A-E2) A completed Designated Representative Training Declaration (17A-E3) A copy of Request for Live Scan Service Form verifying that your fingerprints have been scanned and all applicable fees paid or a set of two completed fingerprint cards and the fingerprint processing fee of $49.00. (See "Fingerprint Requirements" on next page) If you would like notification that the board has received your application, please submit a stamped postcard addressed to yourself. The board will notify you if additional information is needed to process your application package. Fingerprint Requirements California Residents The board will only accept Live Scan Service Forms from California residents. Live Scan will be accepted from residents of other states if the Live Scan service is performed in California. The board will only accept fingerprint cards from residents outside of California. Complete a Live Scan Request form and take all 3 copies to a Live Scan site for fingerprint scanning. Please refer to the Instructions for completing a "Request for Live Scan Service" form. Live Scan sites are located throughout California. For more information about locating a Live Scan site near you, visit the Department of Justice website at http://ag.ca.gov/fingerprints/publications/contact.htm or the sources listed on the bottom of the instructions for completing a "Request for Live Scan Service" form. The lower portion of the Live Scan Request form must be completed by the Live Scan operator verifying that your prints have been scanned and all applicable fees have been paid. Attach the second copy of the form to your application and submit to the board. Note to Applicants Submitting Fingerprints Via Live Scan: While the Live Scan forms contained in the board's application package are pre-slugged to indicate level of service at the DOJ and FBI level, please ensure at the time of Live Scan transmission that the Live Scan operator selects both the DOJ and FBI levels of service. If FBI is not selected at the time of original transmission, you may be required to have your Live Scan redone at another time and have to repay for the DOJ and FBI levels of services again. The board has been notified by the DOJ that effective 9/1/07, if the FBI level of service is not requested at the time of original transmission both DOJ and FBI levels of service will have to be redone. Any issue of cost for resubmission should be handled at the Live Scan Site level. Non California Residents If a designated representative resides out of state they must submit rolled fingerprints on cards provided by the board and include a separate fee of $49 ($32 California Department of Justice (DOJ) fee, and $17 FBI fingerprint processing fee). (Live Scan processing fees are paid directly at the Live Scan site.) You may contact the board to request fingerprint cards at (916) 574-7900. You may also request cards on our website at www.pharmacy.ca.gov.
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