Designated Representative Experience Declaration
Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Designated Representative Experience Declaration Form. This is a California form and can be use in Board Of Pharmacy Statewide.
Loading PDF...
Tags: Designated Representative Experience Declaration, 17A-E2, California Statewide, Board Of Pharmacy
California State Board of Pharmacy
STATE AND CONSUMER SERVICES AGENCY
DEPARTMENT OF CONSUMER AFFAIRS
ARNOLD SCHWARZENEGGER, GOVERNOR
1625 N. Market Blvd, Suite N219, Sacramento, CA 95834
Phone (916) 574-7900
Fax (916) 574-8618
www.pharmacy.ca.gov
DESIGNATED REPRESENTATIVE EXPERIENCE DECLARATION
TO BE COMPLETED BY APPLICANT
(Please print or type)
Name of Applicant
Last
First
Residence Address
Number and Street
City
Home telephone number
Middle
Former
State
Zip Code
Work telephone number
TO BE COMPLETED BY THE PERSON HAVING DIRECT KNOWLEDGE OF APPLICANT’S EXPERIENCE
(Please print or type)
(Name of Applicant)
was employed for at least one year of paid experience related to the distribution or disposition of dangerous drugs or
dangerous devices.
from
to
Number of years
(month/day/year)
(month/day/year)
DO NOT state "current, present or still employed" (use exact dates)
NAME AND ADDRESS OF EMPLOYER
Name of Business
Address
Board of Pharmacy License Number
City
Number and Street
Name of Person Having Direct Knowledge
State
Zip Code
Telephone Number
(please print)
I declare under penalty of perjury under the laws of the State of California that all statements given herein are
true and correct.
Signature of Person Having Direct Knowledge
of Applicant’s Work Experience
17A-E2 (12/04)
Position
Date
American LegalNet, Inc.
www.FormsWorkflow.com
