Application For A Designated Representative License {17A-E}

17A-E - DESIGNATED REPRESENTATIVE LICENSE APPLICATION. This is a California State Board of Pharmacy form used to apply for licensure as a designated representative authorized to oversee the distribution of prescription drugs and devices for a wholesaler. The application collects detailed personal information, education and experience qualifications, training completion, and professional licensing history. It also requires disclosure of ownership interests, disciplinary history, and any conditions that may affect the applicant’s ability to perform duties. Supporting documentation, fingerprinting, and a signed affidavit are required. A person applying for a designated representative-wholesaler license must demonstrate they meet the requirements for licensure pursuant to Business and Professions Code section 4053. Read the application instructions before you complete the application. Failure to provide the required information may result in the application being considered incomplete. Attach additional sheets of paper, if necessary. www.FormsWorkflow.com