Application For Home Medical Device Retailer Exemptee License New And Renewal {CDPH 8695}

CDPH 8695 - HOME MEDICALDEVICE RETAILER EXEMPTEE LICENSE APPLICATION – NEW AND RENEWAL. This form is used for applying for or renewing a license to distribute or dispense prescription medical devices at an HMDR facility in California. It collects the applicant's personal details, qualifications, experience, and current employment information. The form verifies if the applicant meets the minimum qualifications, including educational background, professional certifications, and relevant training. Both the applicant and employer must certify the accuracy of the provided information. The form includes sections for fee payment and must be submitted to the California Department of Public Health with the required documents and fees. Please complete and/or amend this application as is most appropriate to your facility. Include the appropriate fee for each application as indicated in the fee schedule and make check payable to: CA DEPARTMENT OF PUBLIC HEALTH. The application cannot be processed without the appropriate fees, complete documentation and appropriate signatures. Unsigned or incomplete applications cannot be processed and will be returned. www.FormsWorkflow.com