17A-20 (Rev. 6/05)Page 1 of 1 APPLICATION TO STORE PHARMACY RECORDS OFFSITE Please mail original to the Board, DO NOT FAX. If approved, the signed and approved original will be mailed back to the pharmacy. Upon return of the signed, approved waiver from the board, please keep the signed copy in the licensed premises with the self-assessment form. Please type or print Name of pharmacy: Pharmacy license number: Address of pharmacy: Number and Street City State Zip Code Telephone number of pharmacy Address of where records will be kept: Number and Street City State Zip Code Telephone number of off site location: Name of person requesting waiver: Position with pharmacy: Name of pharmacist-in-charge: California pharmacist license number: The board may cancel the authority to store required records offsite. The pharmacy and the pharmacist-in-charge listed above have not failed to produce records pursuant to section 4081 of the California Business and Professions Code or falsified records covered by section 4081 of the California Business and Professions Code within the proceeding five years. I certify under penalty of perjury of the laws of the state of California that all information provided on this application is true and accurate and the pharmacy will comply with requirements for section 1707 of the California Code of Regulations. Signature of person authorized to request waiver Print Name Date Signature of pharmacist-in-charge Print Name Date OFFSITE WAIVER APPROVAL Waiver Number: Date Approved: Board-Authorized Signature: DEPARTMENT OF CONSUMER AFFAIRS California State Board of Pharmacy Fax (916) 574-8618 www.pharmacy.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com