California State Board of Pharmacy STATE AND CONSUMER SERVICES AGENCY 1625 N. Market Blvd, Suite N219, Sacramento, CA 95834 Phone (916) 574-7900 Fax (916) 574-8618 www.pharmacy.ca.gov DEPARTMENT OF CONSUMER AFFAIRS ARNOLD SCHWARZENEGGER, GOVERNOR REPORT OF DESIGNATED REPRESENTATIVE-IN-CHARGE There must be one designated representative or pharmacist chosen as the designated representative-in-charge for each wholesaler or veterinary food-animal drug retailer (vet retailer)* location. If the designated representative-in-charge leaves the employment of the wholesaler or vet retailer, a new designated representative-in-charge must be reported to the board within 30 days. DO NOT USE THIS FORM TO REPORT A CHANGE. Changes in the designated representative-in-charge must be reported on a Change of designated representative-in-Charge (form 17AE-1). The licenses of all designated representatives or pharmacists working at the wholesaler or vet retailer must be current. ALL SECTIONS MUST BE COMPLETED (Please print or type) Name of wholesaler: Permit number (if known) Address : Number and Street Telephone Number: Name of person reporting designated representative-in-charge: ( State Zip Code ) ********** Full name: Residence Address: Telephone Number: ( City DESIGNATED REPRESENTATIVE INFORMATION Last First Number and Street Middle City Date of birth: (Month, Day, Year) ********** EXC license No: State Zip Code *Social Security number: ) Previous name(s) – include maiden name, also known as (AKA’s), “aliases”: I certify under penalty of perjury under the laws of the State of California that all statements, answers and representations made in the foregoing are true and accurate. Signature of person reporting designated representative-in-charge Date Signature of designated representative-in-charge Date *Designated representative for vet retailers must have specific training in addition to that required for wholesale designated representatives. 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-3 (6/05) American LegalNet, Inc. www.FormsWorkflow.com