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 BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY DEPARTMENT OF CONSUMER AFFAIRS GOVERNOR EDMUND G. BROWN JR. DESIGNATED REPRESENTATIVE LICENSE APPLICATION All information requested in this application is mandatory. Failure to provide any information will result in the application being considered incomplete. The information will be used to determine if you qualify for licensure pursuant to California Business and Professions Code section 4053. An applicant for a designated representative license, who fails to complete all the application requirements within 60 days after being notified by the board of deficiencies, may be deemed to have abandoned the application and may be required to file a new application, fee, and meet all the requirements which are in effect at the time of reapplication. Read the application instructions before you complete the application. All questions on this application must be answered and signed by the applicant. If not applicable, indicate N/A. Attach additional sheets of paper, if necessary. MILITARY (Check here if you meet the requirements for expediting your application.) Applicant Information - Please Type or Print VETERAN (Check here if you are a veteran of the US armed services.) Full Legal Name: Last Name: Previous Names (AKA, Maiden Name, Alias, etc.): *Official Mailing/Public Street Address of Record (Street Address, PO Box #, etc.): City: Residence Street Address (if different from above): City: Home#: ( Email Address: **Social Security # or Individual Tax ID #: ) Cell#: ( ) State: Work#: ( Driver's Lic. No: Date of Birth (Month/Day/Year): TAPE A COLOR PASSPORT STYLE PHOTOGRAPH (2"X2") TAKEN WITHIN 60 DAYS OF THE FILING OF THIS APPLICATION NO POLAROID OR SCANNED IMAGES PHOTO MUST BE ON PHOTO First Name: Middle Name: State: Zip Code: Zip Code: ) State: Mandatory Education (check one box) Please indicate how you satisfy the mandatory high school education requirement in Business and Professions Code section 4053(b)(1). High school graduate or foreign equivalent. Attach an official embossed transcript or notarized copy of your high school transcript or foreign secondary school diploma along with a certified translation of the diploma. OR Completed a General Education Development equivalent certificate. Attach an official transcript of your test results or certificate of proficiency. Designated Representative Qualifying Method Please indicate how you qualify for a Designated Representative license pursuant Business and Professions Code section 4053. Experience I have a minimum of one year of paid work experience, in the past three years. Attached is form 17A-E2. OR I meet the prerequisites to take the examination required for licensure as a pharmacist. Attach documentation of your examination eligibility. AND Training I have completed the required training program. Attached is form 17A-E3. License Information: List all state(s), including California, where you hold or have held a license as a designated representative/3PL, intern pharmacist and/or pharmacy technician, and/or any other healthcare professional license. Attach additional sheets if necessary. State Registration Number Active or Inactive Issued Date Expiration Date Enf. 1st Check Photo HS Doc Exp. Affidavit Training Affidavit FP Cards Fee /Live Scan FP Cards Sent DOJ Clear Date: FBI Clear Date: Enf 2nd Check License no. Date issued By: Receipt # Amount Date Cashiered American LegalNet, Inc. www.FormsWorkFlow.com 17A-E (Rev. 11/2015) Page 1 of 4 You must provide a written explanation for all affirmative answers indicated below. Failure to do so may result in this application being deemed incomplete and being withdrawn. 1. Do you have a mental illness or physical illness that in any way impairs or limits your ability to practice your Yes profession with reasonable skill and safety without exposing others to significant health or safety risks? If "yes," attach a statement of explanation. If "no," proceed to #2. Are the limitations caused by your mental illness or physical illness reduced or improved because you receive No ongoing treatment or participate in a monitoring program? Yes If "yes," attach a statement of explanation. If you do receive ongoing treatment or participate in a monitoring program, the board will make an individualized assessment of the nature, the severity and the duration of the risks associated with an ongoing mental illness or physical illness to determine whether an unrestricted license should be issued, whether conditions should be imposed, or whether you are not eligible for license. Do you currently engage or have previously engaged in the illegal use of controlled substances? Yes If "yes," are you currently participating in a supervised substance abuse program or professional assistance program which monitors you in order to assure that you are not engaging in the illegal use of controlled dangerous substances? Yes No Attach a statement of explanation. 3. Do you currently participant in a substance abuse program or have previously participated in a substance abuse program in the past five years? No No 2. Yes No If "yes," are you currently participating in a supervised substance abuse program or professional assistance program which monitors you to ensure you are maintaining sobriety? Yes No Attach a statement of explanation. 4. Has disciplinary action ever been taken against your designated representative, pharmacist, intern pharmacist and/or pharmacy technician license in this state or any other state? If "yes," attach a statement of explanation to Yes include circumstances, type of action, date of action and type of license, registration or permit involved. 5. Have you ever had an application for a designated representative, pharmacist, intern pharmacist and/or pharmacy technician license denied in this state or any other state? If "yes," attach a statement of explanation Yes to include circumstances, type of action, date of action and type of license, registration or permit involved. 6. Have you ever had a pharmacy license, or any professional or vocational license or registration, denied, suspended, revoked, placed on probation or had other disciplinary action taken by this or any other government Yes authority in California or any other state? If "yes," provide the name of company, type of permit, type of a