Designated Representative Training Declaration
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Designated Representative Training Declaration Form. This is a California form and can be use in Board Of Pharmacy Statewide.
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Tags: Designated Representative Training Declaration, 17A-E3, 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* TRAINING DECLARATION
TO BE COMPLETED BY APPLICANT
(Please print or type)
Name of Applicant
Residence Address
Last
First
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 TRAINING
The individual applying for certification as a designated representative in California has completed training required
by Section 4053 of the California Business and Professions Code that addressed, at a minimum:
• Knowledge and understanding of California and federal laws regarding the distribution of dangerous drugs and
dangerous devices;
• Knowledge and understanding of California and federal laws regarding the distribution of controlled substances;
• Knowledge and understanding of United States Pharmacopoeia standards for the safe storage and handling of
drugs;
• Knowledge and understanding of quality control systems; and
• Knowledge and understanding of prescription terminology, abbreviations, dosages and format.
THIS TRAINING WAS PROVIDED BY
(Please print or type)
Name of company, school or individual providing the training
Name of Person Having Direct Knowledge of Training
Address
City
From
State
Zip Code
to
Telephone Number
Number of hours
(month/day/year)
(month/day/year)
DO NOT use "current, present or still employed" (use exact dates)
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 Training
Position
Date
*Note: Under California law, the name used to describe any individual who is in charge of any wholesale drug
premises (in California or elsewhere) will change on January 1, 2006, from the former name, exemptee, to
designated representative. For conventional use, the board will refer to such an individual as a designated
representative throughout this application.
17A-E3 (1/05)
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