California State Board of Pharmacy 1625 N. Market Blvd., Suite N-219 Sacramento, CA 95834-6237 Phone (916) 574-7900 Fax (916) 327-6308 www.pharmacy.ca.gov BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY DEPARTMENT OF CONSUMER AFFAIRS GOVERNOR EDMUND G. BROWN JR. DESIGNATED REPRESENTATIVE APPLICATION INSTRUCTIONS A person applying for a designated representative license must demonstrate he/she meets the requirements for licensure pursuant to Business and Professions Code section 4053. HOW LONG WILL IT TAKE TO PROCESS MY APPLICATION? It takes the board 45 days to process your application. You will be notified by mail if your application is not complete. Please do not contact the board to check on your application unless it has been on file for over 60 days. If your check has cleared your bank, the board has received your application. To check if your license was issued, go to www.pharmacy.ca.gov. Select "Verify a License" and enter your name. It takes four to six weeks from the date a license is issued to receive the license in the mail. WHAT MAKES AN APPLICATION COMPLETE? Use the check boxes below to be sure your application is complete before mailing it. If your application is not complete, you will receive a "Deficiency Letter" in the mail. You will then have 60 days to submit the required item(s). If you do not submit the required item(s) within 60 days, you may have to file a new application with new fees and meet any new requirements. APPLICATION FEE $330: Include a check or money order for $330 made payable to the Board of Pharmacy. This fee is not refundable. APPLICATION FOR A DESIGNATED REPRESENTATIVE LICENSE (form 17A-E): Complete the entire application. A licensed pharmacist is not required to be licensed as a designated representative to act as a designative representative-in-charge for a wholesaler if he/she is licensed as a pharmacist in the home state in which the wholesale facility is located. AVOID COMMON MISTAKES Look at your state issued driver's license or state issued identification card prior to completing the application. The name on each form listed below must be EXACTLY THE SAME as the name on your state driver's license or state issued identification card. If you have a hyphenated name, two last names or two first names, you need to list your name on each of the following documents to match that of your state issued identification: Designated Representative Application Request for Live Scan form or fingerprint cards Have you ever used a different name? List each prior name on the application under Previous Names. Did you have a maiden name, married name, former name, AKA? Have you ever used Jr., Sr., II, etc., with your name? If you do not list all of your previous names, the board may not be able to locate, match or verify your documents. Do not leave anything blank: Use "N/A" if a question doesn't apply to you. You must sign and date the application. No one else can sign it for you. Signatures must be original and dated within 60 days of filing the application. No electronic, stamped, copies or faxed signatures will be accepted. 17M-27 (Rev 11/2015) Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com  U.S. Social Security Number or Individual Taxpayer Identification Number (ITIN): Disclosure of your U.S. social security number or individual taxpayer identification number is mandatory and must be included on the application. PHOTO: Attach a passport-style photo to page 1 of the application (glossy, color photo 2"x2") taken within 60 days of filing the application. DO NOT provide scanned images, Polaroids, or black-and-white photos. MILITARY EXPEDITE: To qualify for expedite review, you must meet one of the following criteria. A. Military Veteran: Please submit a copy of your DD214 with your application. OR B. Active Duty Military-Spouses or Partners: If your spouse or partner is an active duty member of the U.S. Armed Forces and you hold a current license in another state, please provide the following: Attach a copy of your current license in another state, district, or territory of the United States documenting the profession or vocation for which you seek license from the board. Attach a copy of the marriage certificate, or certified declaration/registration of domestic partnership, or other evidence of legal union. Attach a copy of your spouse or partner's military orders establishing duty station in California. BASIC EDUCATION: You must be a high school graduate or have a General Education Degree certificate equivalent. Attach ONE of the following (A, B, C, or D): A. U.S. High School Graduate: Attach an official, embossed transcript (academic record) or notarized copy of your high school transcript. It must have the graduation date on it. To get a copy of your high school transcript, contact your high school or its school district office. B. Foreign High School Graduate: Attach a notarized copy of your foreign secondary school diploma or certificate OR a notarized copy of your foreign secondary school transcripts. If not in English, then include a certified translation in English. The translation may be from an evaluation service that states your education is equal to graduating high school in the U.S. C. California High School Equivalency Test: Attached 1, 2, or 3 to show documentation of completing one of the three California High School Equivalency Tests. 1. General Educational Development (GED): Attach an official transcript of your test results or equivalent. GED test results are official only if they are earned through an authorized GED Testing Center. To get your GED transcripts, go to http://www.gedtestingservice.com/testers/gedrequest-a-transcript. If your GED is from another state, you may need to request an official transcript of your GED test results from the agency in that state. 2. HiSET: Attach an official transcript of your test results or equivalent. HiSET test results are official if they are earned through an authorized HiSET Testing Center. To request your HiSET transcripts, go to www.diplomasender.com. 3. TASC: Attach an official transcript of your test results or equivalent. TASC test results are official if they are earned through an authorized TASC Testing Center. To request your TASC transcripts, go to http://www.tasctest.com/. 17M-27 (Rev 11/2015) Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com D. Certificate Equivalent ­ Attach an official "Certificate of Proficiency" showing you passed the California High