5.(The following questions are for NEW APPLICANTS ONLY)Please provide the following information to determine if you meet the minimum qualifications.Do you have a high school diploma or equivalent? (Attach a copy) Yes No Do you hold any of the following professional certifications or licenses: (Attach a copy) Respiratory Therapist LVN RN PT OT Pharmacy Technician Other Have you had one year or more paid experience related to the distribution or dispensing of dangerous drugs or dangerous devices? (Provide proof of 1 year experience) Yes No Have you completed training program(s) that address the following: (Attach copy of completed training certificate) State and Federal laws relating to the distribution of dangerous drugs and dangerous devices? Yes No State and Federal laws relating to the distribution of controlled substances? Yes No Knowledge and understanding of quality control systems? Yes No The United States Pharmacopoeia standards relating to the safe storage and handling of drugs? Yes No The safe storage and handling of home medical devices? Yes No Prescription terminology, abbreviations, and format? Yes No For all of the above questions answered yes, you must submit appropriate proof to verify qualifications. 6.Certification of Exemptee -Please read carefully and sign belowI understand that falsification of the information on this form may constitute grounds for denial or revocation of the license. I herebycertify under penalty of perjury under the laws of the State of California to the truth and accuracy of all statements, answers andrepresentations made in this application, including all supplementary statements. I also certify that I personally completed thisapplication and have read and understand the instructions attached to this application.Applicant Exemptee signature: (in full, no initials) Date: Date Received: CID # Amount: $ 002 002 License Number: PLEASE DO NOT WRITE ABOVE THIS LINE002 Read instructions on attached sheet. Unsigned or incomplete applications will not be processed.002 New Exemptee Relocation Ownership Change Additional License Renewal 1.Legal Name of Applicant:Last First Middle Former Residence address: Number and Street City State Zip Code Home phone number: Date of birth: If Renewal, Exemptee license No: ( ) 2.Name of HMDR facility where Exemptee will be working and / Business days and hours when Exemptee will be dispensing ordistributing prescription devices. (If currently employed by a HMDR facility.)Address of HMDR facility: Number and Street City State Zip Code Work phone number: HMDR license number of employer (leave blank if unknown): Expiration date: ( ) 3.Contact Name (if different from exemptee name):4.Mailing Address (if different from HMDR facility):City State Zip Code State of California227Health and Human Services Agency California Department of Public Health Food and Drug Branch APPLICATION FOR HOME MEDICAL DEVICE RETAILER EXEMPTEE LICENSE 226 NEW AND RENEWAL CDPH 8695 (0/1) Fund Code 3018 Index 5624 PCA 76223 Receipt Source 125700 Agency Source 0049 Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 003 (attach a separate sheet if necessary) 14.Certification of Employer 226 Read carefully and sign belowI hereby certify that the application completed on this form is being presented to the Food and Drug Branch with myknowledge and approval. Also, it is my understanding that a person certified by the Food and Drug Branch must beon the premises and actively supervising operations at all times when prescription devices are being dispensed. Icertify under penalty of perjury under the laws of the State of California to the truth and accuracy of all statements,answers, and representations made in the foregoing application, including all supplementary statements.15.Employer222s original signature: (in blue ink)Title of person signing: Date: 16.License Fee Due (Fee is Non Refundable)Enter Fee Below: License fee due (see page 3) $ 003 7.Legal Name of Home Medical Device Retailer:HMDR license number: Business name: (if different) Facility Address: Number and Street City State Zip Code 8.The applicant medical device retailer will sell the following products: (Check all that apply)Respiratory Equipment / O2 Supplies Incontinence Supplies Walkers, Canes, Commodes CPAPS, BiPAPS Custom Wheelchairs Hospital Beds / Mattresses TENS Units Power Wheelchairs Other: Describe Below or attach list of products. Infusion Pumps Manual Wheelchairs Catheters Nutritional Supplements CPM Machines Diabetic Test Supplies 9.Does this Home Medical Device Retailer currently employ the person whose name appears on this application?Yes No 10.Will this person replace an Exemptee licensed by the California Department of Public Health?Yes No (Attach copy) Name of Exemptee being replaced : Exemptee Number: 11.List business hours and days that the applicant will be working at this facility: 12.Enter other Exemptee license number(s) that applicant possesses: 13.If applicant is working at various locations explain how facility intends to provide coverage in applicant222s absence: State of California227Health and Human Services Agency003 California Department of Public Health Food and Drug Branch THIS AREA IS TO BE COMPLETED BY THE EMPLOYER (If Applicant is currently employed by a HMDR facility.) Make Checks Payable to: CALIFORNIA DEPARTMENT OF PUBLIC HEALTH See page 3 for mailing address CDPH 8695 (0/1) Fund Code 3018 Index 5624 PCA 76223 Receipt Source 125700 Agency Source 0049 Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 State of California227Health and Human Services Agency California Department of Public Health Food and Drug Branch Home Medical Device Retailer Exemptee License A pplication Instructions Please complete and/or amend this application as is most appropriate to your facility. Include the appropriate fee for each application as indicated in the fee schedule and make check payable to: CA DEPARTMENT OF PUBLIC HEALTH. The application cannot be processed without the appropriate fees, complete documentation and appropriate signatures. Unsigned or incomplete applications cannot be processed and will be returned. The following are further instructions on how to complete this application: 1.Your Information: Your legal name as it is to appear on the license issued by the Department of Public Health. Residence address:Enter the number, street, city, state and Zip code for your residence. If this is a renewal, enter your current Exemptee licensenumber.2.Employer Information: The legal name of the Home Medical Device Retailer facility where you will be distributing prescriptiondevices. (If currently employed by a HMDR facility.) Address: Enter the number, street, city, state and Zip code for this facility.3.Correspondent: Enter the name of the person to contact for information regarding this application and their title.4.Mailing Address: This address is where licensing information is to be sent if the address is a different location than the Employeraddress.5.Minimum qualifications:Education: High school diploma GED or equivalent. Attach copies of any applicable certifications or licenses that youmay hold.Work Experience: One or more years paid experience, attach dates, name(s) of employer(s), and addresses. Trainingmust have been supervised by a licensed exemptee, Pharmacist-In-Charge or equivalent.Training Programs: Indicate by yes or no the training you have completed specific to the five topics listed. Attachcopies of certificates or transcripts.6.Certification of Applicant: After reading the instruction paragraph your signature is needed, please sign in full (no initials) anddate.Numbers 7 through 16 are to be completed by the employer. (If currently employed by a HMDR facility.) 7.Name of Firm: Enter the full name of the business, HMDR license: Enter the current Home Medical Device Retailer facility licensenumber. Corporate Name: Name of corporation if different from HMDR name. Facility Address: Enter the number, street, city,state and Zip code for this facility location.8.Products type: Place an (x) in the boxes that correct