Fillable INTERN PHARMACIST APPLICATION INSTRUCTIONS (California)

Fill Online, Printable, Fillable, Blank INTERN PHARMACIST APPLICATION INSTRUCTIONS (California) Form

Use Fill to complete blank online CALIFORNIA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

INTERN PHARMACIST APPLICATION INSTRUCTIONS (California)

On average this form takes 24 minutes to complete

The INTERN PHARMACIST APPLICATION INSTRUCTIONS (California) form is 18 pages long and contains:

  • 0 signatures
  • 50 check-boxes
  • 71 other fields

Country of origin: US
File type: PDF

BROWSE CALIFORNIA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
California State Board of Pharmacy
Business, Consumer Services and Housing Agency
2720 Gateway Oaks Drive, Suite 100 Department of Consumer Affairs
Sacramento, CA 95833 Gavin Newsom, Governor
Phone: (916) 518-3100 Fax: (916) 574-8618
www.pharmacy.ca.gov
INTERN PHARMACIST APPLICATION INSTRUCTIONS
HOW LONG WILL IT TAKE TO PROCESS MY APPLICATION?
Allow the Board 30 days to review your application.
You will be notified in writing if your application is incomplete. To facilitate electronic communication,
please provide an email address that you check regularly.
Please do not contact the Board to check on the status of your application unless your application has
been on file for over 45 days.
If your check has cleared your bank, the Board has received your application.
Once you have completed all the requirements for licensure and the Board has approved the issuance
of your license, you will receive an email notifying you of the issuance of your license. In addition, you
may verify your license at www.pharmacy.ca.gov. Select “Verify a License” and enter your name.
Please allow four to six weeks from the date a license is issued to receive the license in the mail.
WHAT MAKES AN APPLICATION COMPLETE
Please review 1-10 to ensure your application is complete before mailing it to the Board.
• If your application is not complete, you will receive a “Deficiency Notice” via email.
• Your license will not be issued until the Board receives the required item(s) identified in your deficiency
notice and approves your application. Failure to complete your application within one year from the date
the Board notified you of the deficiencies, may result in your application being considered abandoned and
withdrawn.
1. APPLICATION FEE IS $230: When you send your application, include a check or money order made payable
to the California State Board of Pharmacy. The application fee is non-refundable.
2. APPLICATION FOR REGISTRATION AS AN INTERN PHARMACIST (form 17A-17): Complete the entire
application. It is preferable to complete the application online, print, then sign (wet signature) and date the
application. To facilitate electronic communication, please provide an email address that you check
regularly.
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 issued 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:
Intern Pharmacist Application,
Request for Live Scan form or fingerprint cards, and
Self-Query Report.
• 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?
1
17M-42 (Rev 1/2021)
If you do not list all of your previous names, the Board may not locate, match or verify your
documents.
Do you have a pharmacy technician license issued in another name? If yes, submit a copy of your
state issued identification for the Board to update your name.
• Do not leave anything blank; use “N/A” if a question doesn’t apply to you.
• Do not let your school fill out your application.
• Sign and date the application within 60 days of filing the application. No one else can sign it for you.
Electronic, stamped, copies or faxed signatures or signatures that do not meet the above requirements
may result in an incomplete application.
3. U.S. SOCIAL SECURITY NUMBER OR INDIVIDUAL TAXPAYER IDENTIFICATION NUMBER (ITIN): You are
required to disclose your U.S. social security number or Individual Taxpayer Identification Number (ITIN). It
must be included on the application and on the Self-Query Report.
4. PHOTO: Attach a passport-style photo to page 1 of the application (2”x2” glossy, colored photo) taken
within 60 days of filing the application. DO NOT provide scanned images, Polaroids, or black-and-white
photos.
5. MILITARY EXPEDITE: The Board will expedite review of an application that meets one of the following
criteria (A, B, or C).
A. Serving in the Military: Are you currently serving in the United States military?
Attach a copy of your military identification.
B. Military Veteran: Have you ever served in the United States military?
Please attach a copy of your DD214 with your application.
C. 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:
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 licensure from the Board.
A copy of the marriage certificate, certified declaration/registration of domestic partnership, or
other evidence of legal union.
A copy of your spouse or partner’s military orders establishing duty station in California.
6. REFUGEE EXPEDITE: The Board will expedite the review of an application that meets one of the following
criteria (A, B, or C). Please attach one of the items listed under acceptable documentation.
A. You were admitted to the United States as a refugee pursuant to section 1157 of title 8 of the United
States Code;
B. You were granted asylum by the Secretary of Homeland Security or the United States Attorney General
pursuant to section 1158 of title 8 of the United States Code; or,
C. You have a special immigrant visa and were granted a status pursuant to section 1244 of Public Law
110-181, Public Law 109-163, or section 602(b) of title VI of division F of Public Law 111-8, relating to
Iraqi and Afghan translators/interpreters or those who worked for or on behalf of the United States
government.
2
17M-42 (Rev 1/2021)
ACCEPTABLE DOCUMENTATION
• Form I-94, Arrival/Departure Record, with an admission class code such as “RE” (Refugee) or “AY”
(Asylee) or other information designating the person a refugee or asylee.
• Special immigrant visa that includes the of “SI” or “SQ.”
• Permanent Resident Card (Form I-551), commonly known as a “Green Card,” with a category
designation indicating that the person was admitted as a refugee or asylee.
• An order from a court of competent jurisdiction or other documentary evidence that provides
reasonable assurance that the applicant qualifies for expedited licensure.
7. MANDATORY EDUCATION – To qualify for an intern pharmacist license, you must submit one of the
following (A, B, C, or D):
A. Enrolled in a School of Pharmacy – If you are enrolled in a school of pharmacy recognized by the Board,
you must submit the Intern Pharmacist Education Affidavit (page 4 of the application 17A-17) with your
application. This form is to be completed by the dean of the school of pharmacy.
OR
B. Graduate of a School of Pharmacy - If you are a graduate from a school of pharmacy recognized by the
Board and you are applying to become licensed as a pharmacist in California, you must submit a
Pharmacist Examination for Licensure Application (17A-1) and have your school of pharmacy mail your
official transcript, which indicates your degree earned and date conferred, directly to the California State
Board of Pharmacy. OR
C. Foreign Graduate of School of Pharmacy - If you are a graduate of a foreign school of pharmacy, submit
a copy of your Foreign Pharmacy Graduate Examination Committee (FPGEC) certificate issued by the
National Association of Boards of Pharmacy.
OR
D. Re-enrolled in a School of Pharmacy – If you have failed the pharmacist licensure examination four
times and you have re-enrolled in a school of pharmacy recognized by the Board, submit the Intern
Pharmacist Education Affidavit (page 4 of the application 17A-17) with your application. This form is to
be completed by the dean of the school of pharmacy.
8. VERIFICATION OF LICENSE IN ANOTHER STATE: If you currently hold or previously held a license in another
state as a pharmacist, intern pharmacist, pharmacy technician, designated representative, and/or other
health care professional, request each state agency to verify your license by completing the required
Verification of License in Another State form (17A-16).
9. SELF-QUERY REPORT: Include a sealed, original Self-Query Report from the National Practitioner Data Bank
(NPDB). It must be dated within 60 days of filing the application.
• Self-Query Reports that have been opened will not be accepted.
• The name on your Self-Query Report must be EXACTLY THE SAME as the name on your application.
• Your U.S. social security number or ITIN must be listed on your Self-Query Report.
• To request a Self-Query Report, go to the NPDB’s Web site at http://www.npdb.hrsa.gov/ or the
direct link at https://www.npdb.hrsa.gov/ext/selfquery/SQHome.jsp
• NPDB’s contact number (800) 767-6732 or TDD (703) 802-9395. Their Web site has a fact sheet and
answers to frequently asked questions. The Board is not able to assist you with requesting the Self-
Query Report. For help, contact the NPDB directly.
• You must pay the fee directly to NPDB.
• You must submit a new Self-Query Report even if one was submitted with a previous application.
3
17M-42 (Rev 1/2021)
10. FINGERPRINTS:
• California residents must use Live Scan. Nonresidents can visit California to complete a Live Scan
or submit fingerprints on cards supplied by the Board. The fingerprint cards must be processed at
a location authorized to complete fingerprint cards for the DOJ/FBI (e.g. law enforcement agency)
in the state the services are rendered.
• DO NOT complete the Live Scan service or fingerprint cards until you are ready to send in your
application.
• You must submit a copy of your Live Scan receipt or two rolled fingerprint cards with your
application
• Each application requires you to complete a new Live Scan or submit new fingerprint cards.
• The Live Scan site may charge a processing fee.
• The Board will accept fingerprint responses only from the California Department of Justice (DOJ)
and Federal Bureau of Investigation (FBI).
Please complete and attach ONE of the following (A or B):
A. California Resident: Attach a copy of your completed Live Scan receipt. The receipt shows you
completed the Live Scan.
• California residents must use Live Scan only.
• To find a Live Scan location, go to https://oag.ca.gov/fingerprints/locations
• Live Scan operators can make mistakes. Be proactive; make sure everything the operator keys in
to their computer is correct before the operator transmits your prints to the Department of
Justice.
Make sure the following information is correct when you complete your Live Scan:
• Type of License/Certification/Permit or Working Title: Pharmacy Intern-Section 4114
• Full Name: Must be EXACTLY THE SAME as the name on your state issued driver’s license or state
issued identification card (Jr., II, etc., must be included). It must also be EXACTLY THE SAME as the
name on your application and your Self-Query Report.
• Date of Birth: Must be correct.
• Social Security Number: Must be included and be correct, unless you have an ITIN. If you have an
ITIN, this field should be left blank.
• Level of Service: Must include both DOJ and FBI.
B. Non-California Resident: You may visit California and complete Live Scan. If you cannot, then you
must submit two rolled fingerprint cards with your application.
• You must use fingerprint cards from the Board of Pharmacy.
• Request fingerprint cards through the Board’s online services at
https://www.dca.ca.gov/webapps/pharmacy/pubs_request.php or email rxforms@dca.ca.gov.
• Fee: Include fingerprint card processing fee of $49 ($32 DOJ and $17 FBI), made payable to the
Board of Pharmacy.
• You can send one check or money order for both the application processing fee and fingerprint
card processing fee.
• Print legibly or type your personal information on the fingerprint cards. If your personal
information is not legible and DOJ enters your information incorrectly, you will be responsible to
submit new fingerprint cards and pay the $49 fingerprint card processing fee again.
4
17M-42 (Rev 1/2021)
• The fingerprint cards must be processed at a location authorized to complete fingerprint cards for
the DOJ/FBI (e.g. law enforcement agency) in the state the services are rendered.
• Fingerprint clearances from cards take about six weeks longer than Live Scan.
• Poor quality prints will be rejected and will cause delay because new fingerprint cards will be
required.
5
17M-42 (Rev 1/2021)
______________________________ _______ _____________________________ _____________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
________________________________ ______________________________ ________________________
_______________________________________________ _______________________________________
________________________________________ ________________________________________________
California State Board of Pharmacy
2720 Gateway Oaks, Suite 100
Sacramento, CA 95833
Phone: (916) 518-3100 Fax: (916) 574-8618
www.pharmacy.ca.gov
Business, Consumer Services and Housing Agency
Department of Consumer Affairs
Gavin Newsom, Governor
INTERN PHARMACIST APPLICATION
Please read the application instructions before you complete the application. Failure to provide the required
information may result in the application being considered incomplete. Attach additional sheets of paper, if
necessary. The information will be used to determine if you qualify for licensure
pursuant to California Business and Professions Code sections 4208 and 4209.
TAPE A COLOR PASSPORT
STYLE 2”X2” PHOTO
TAKEN WITHIN
60 DAYS OF THE FILING
OF THIS APPLICATION
NO POLAROID
OR
SCANNED IMAGES
PHOTO MUST BE ON
PHOTO QUALITY PAPER
Military Expedite (Please check one of the following, if applicable)
_____ MILITARY (Are you serving in the United States military?)
_____ VETERAN (Have you ever served in the United States military?)
_____ ACTIVE DUTY MILITARY (Do you have a spouse or partner serving active duty
in the military?)
Refugee Expedite (Please check one of the following, if applicable)
_____Refugee pursuant to section 1157 of title 8 of the United States Code;
_____Refugee granted asylum by the Secretary of Homeland Security or the Attorney
General of the United States pursuant to section 1158 of title 8 of the United States Code; or,
_____ Refugee with a special immigrant visa that has been granted a status pursuant to section 1244 of
Public Law 110-181, Public Law 109-163, or section 602(b) of title VI of division F of Public Law 111-8.
Applicant Information - Please Type or Print
Full Legal Name - Last Name Suffix First Name Middle Name
Previous Names (AKA, Maiden Name, Alias, etc.)
*Official Mailing/Public Address of Record – Street/PO BOX City State Zip Code
Residence Address - Street City State Zip Code
Telephone Numbers - Home Cell Work
Driver’s License Number State Email Address
Date of Birth (Month/Day/Year) **US Social Security Number or ITIN
Have you ever been licensed in California as an intern pharmacist?
Yes ____ No____ If Yes, provide the date and intern pharmacist license number______________________
THIS SECTION IS FOR BOARD USE ONLY
App Fee: ____
Enf. Check: ____
Photo: ____
School Code: ____
FPGEC: ____
Affidavit:
Qualify Code: _____
SQ: _____
FP Cards Fees/Live Scan:
DOJ Date: ____________
FBI Date: ____________
License #:_______________
Date issued: ____________
Date expires: ___________
Receipt #: ________________
Date Cashiered: ___________
Amount: _________________
17A-17 (/2021) 1
Graduate from a Foreign School of Pharmacy, provide:
Name(s) of University, College, or School of Pharmacy Country Date of Graduation Degree
______________________________________________ _____________ _________________ ____________
______________________________________________ _____________ _________________ ____________
______ ___________________________ __________________ ____________ _______________________
______ ___________________________ __________________ ____________ _______________________
______ ___________________________ __________________ ____________ _______________________
Enrolled in or Graduated from a United States School of Pharmacy, provide:
Name(s) of University, College, or School of Pharmacy Country Date of Graduation Degree
License Information List all state(s) where you are or have previously been licensed as a pharmacist, intern
pharmacist, pharmacy technician, any type of designated representative, and/or other healthcare professional,
including California. All licenses both active and inactive held outside of California must be verified on the
Verification of Licensure in Another State (form 17A-16).
State License Type and Number Active or Inactive Issued Date Expiration Date
APPLICANTS MUST ANSWER THE FOLLOWING QUESTIONS (Attach additional sheets of paper if necessary)
1. California Examinations for Pharmacists
A. Have you taken the California Practice Standards and Jurisprudence Examination for Pharmacists (CPJE)
before?
Yes ____ No____ If Yes, provide the exam date(s): ___________________________________________
B. Have you passed the CPJE?
Yes ____ No____ If Yes, provide the exam date: _____________________________________________
C. Have you previously taken a California pharmacist examination and the results were withheld?
Yes ____ No____ If Yes, provide the exam date: _____________________________________________
E. Have you ever been expelled from a California pharmacist examination?
Yes ____ No____ If Yes, provide the exam date: _____________________________________________
2. North American Pharmacist Licensure Examination (NAPLEX)
A. Have you taken the NAPLEX?
Yes ____ No____ If Yes, provide the exam date(s) and primary state(s): __________________________
B. Have you passed the NAPLEX?
Yes ____ No____ If Yes, provide the exam date and primary state: ______________________________
C. Have you previously taken the NAPLEX and the results were withheld?
Yes ____ No____ If Yes, provide the date and primary state: __________________________________
D. Have you ever been expelled from the NAPLEX?
Yes ____ No____ If Yes, provide the date and primary state: __________________________________
17A-17 (1/2021) 2
3. Ownership Information
A. Are you currently or have you previously been listed as a corporate officer, partner, owner, manager,
member, administrator, or medical director on a license to conduct a pharmacy, wholesaler, third-
party logistics provider, or any other entity licensed in any state, territory, foreign country, or other
jurisdiction?
Yes ____ No____ If Yes, attach a statement of explanation including company name, type of license,
license number, and identify the state, territory, foreign country, or other jurisdiction where licensed.
4. Disciplinary History
The following questions pertain to a license sought or held in any state, territory, foreign country, or other
jurisdiction. For any affirmative answer, attach a statement of explanation including type of license, license
number, type of action, date of action, and identify the state, territory, foreign country, or other
jurisdiction.
A. Have you ever had an application for pharmacy technician, intern pharmacist, pharmacist, any type of
designated representative, and/or any other professional or vocational license or registration denied?
Yes ____ No____
B. Have you ever had a pharmacy technician, intern pharmacist, pharmacist, any type of designated
representative, and/or any other professional or vocational license or registration suspended, revoked,
placed on probation, or had other disciplinary action taken against it?
Yes ____ No____
C. Have you ever had a pharmacy, wholesaler, third-party logistics provider, and/or any other entity
license denied, suspended, revoked, placed on probation, or had other disciplinary action taken against
a license you hold?
Yes ____ No____
5. Practice Impairment or Limitation
The board makes an individualized assessment of the nature, the severity, and the duration of the risks
associated with any identified condition to determine whether an unrestricted license should be issued,
whether conditions should be imposed, or whether the applicant is not qualified for licensure. If the board
is unable to make a determination based on the information provided, the board may require an applicant
to be examined by one or more physicians or psychologists, at the board’s cost, to obtain an independent
evaluation of whether the applicant is able to safely practice despite the mental illness or physical illness
affecting competency. A copy of any independent evaluation would be provided to the applicant.
A. Have you ever been diagnosed with an emotional, mental, or behavioral disorder that may impair your
ability to practice safely?
Yes ____ No____ If Yes, attach a statement of explanation.
B. Have you ever been diagnosed with a physical condition that may impair your ability to practice safely?
Yes ____ No____ If Yes, attach a statement of explanation.
C. Do you have any other condition that may in any way impair or limit your ability to practice safely?
Yes ____ No____ If Yes, attach a statement of explanation.
17A-17 (1/2021) 3
D. Have you ever participated in, been enrolled in, or required to enter into any drug, alcohol, or
substance abuse recovery program or impaired practitioner program?
Yes ____ No____ If Yes, attach a statement of explanation.
E. If you answered “Yes” to questions listed under 5 (A through D) above, have you ever received
treatment or participated in any program that improves your ability to practice safely?
Yes ____ No____ N/A____ If Yes, attach a statement of explanation.
Reminder: The Self-Query Report by the National Practitioner Data Bank (NPDB)
must be submitted with your application.
APPLICANT AFFIDAVIT
You must provide a written explanation for all affirmative answers. Failure to provide any of the requested
information may result in the application being deemed incomplete. Falsification of the information on this
application may constitute grounds for denial or revocation of the license. Any application not completed
within one year after being notified by the board of deficiencies may be deemed to have been abandoned,
and the applicant will be required to file a new application and meet all the requirements that are in effect at
the time of application. Fees applied to this application are not transferable or refundable.
Collection and Use of Personal Information. The California State Board of Pharmacy of the Department of
Consumer Affairs collects the personal information requested on this form pursuant to Business and
Professions Code sections 30 and 4000 and following and California Code of Regulations title 16, division 17.
The California State Board of Pharmacy uses this information principally to identify and evaluate applicants for
licensure, issue, and renew licenses, and enforce licensing standards set by law and regulation.
Access to Personal Information. You may review the records maintained by the California State Board of
Pharmacy that contain your personal information, as permitted by the Information Practices Act. The official
responsible for maintaining records is the Executive Officer at the board’s address listed on the application.
Each individual has the right to review the files or records maintained by the board, unless confidential and
exempt by law.
Possible Disclosure of Personal Information. We make every effort to protect the personal information you
provide us. The information you provide, however, may be disclosed under the following circumstances:
• In response to a Public Records Act request (Government Code section 6250 and following), as allowed by
the Information Practices Act (Civil Code section 1798 and following);
• To another government agency as required or permitted by state or federal law; or
• In response to a court or administrative order, a subpoena, or a search warrant.
*Address of Record: Once you are licensed with the board, the address of record you enter on this application
is considered public information pursuant to the Information Practices Act (Civil Code section 1798 and
following) and the Public Records Act (Government Code section 6250 and following) and will be available on
the Internet. This is where the board will mail all official correspondence. If you do not wish your residence
address to be available to the public, you may provide a post office box number or a personal mail box (PMB).
However, if your address of record is not your residence address, you must also provide your residence
address to the board, in which case your residence will not be available to the public.
17A-17 (1/2021) 4
**Disclosure of your U.S. Social Security Number or Individual Taxpayer Identification Number (ITIN) is
mandatory. Section 30 of the Business and Professions Code, section 17520 of the Family Code, and Public
Law 94-455 (42 USC § 405(c)(2)(C)) authorize collection of your social security number or individual taxpayer
identification number. Your social security number or individual taxpayer identification number will be used
exclusively for tax enforcement purposes, for purposes of compliance with any judgment or order for child or
family support in accordance with section 17520 of the Family Law Code, or for verification of license or
examination status by a licensing or examination entity, which utilizes a national examination and where
licensure is reciprocal with the requesting state. If you fail to disclose your social security number or individual
taxpayer identification number, your application will not be processed and you may be reported to the
Franchise Tax Board, which may assess a $100 penalty against you.
NOTICE: The State Board of Equalization and the Franchise Tax Board may share taxpayer information with the
board. You are obligated to pay your state tax obligation. This application may be denied or your license may
be suspended if your state tax obligation is not paid.
MANDATORY REPORTER
Under California law, each person licensed by the California State Board of Pharmacy is a “mandated reporter”
for both child and elder abuse or neglect laws. California Penal Code section 11166 and Welfare and
Institutions Code section 15630 require that all mandated reporters make a report to an agency specified in
Penal Code section 11165.9 and Welfare and Institutions Code section 15630(b)(1) [generally law
enforcement, state, and/or county adult protective services agencies, etc.] whenever the mandated reporter,
in his or her professional capacity or within the scope of his or her employment, has knowledge of or observes
a child, elder, and/or dependent adult whom the mandated reporter knows or reasonably suspects has been
the victim of child abuse or elder abuse or neglect. The mandated reporter must contact by telephone
immediately or as soon as possible to make a report to the appropriate agency(ies) or as soon as is practicably
possible. The mandated reporter must prepare and send a written report thereof within two working days or
36 hours of receiving the information concerning the incident.
Failure to comply with the requirements of the laws above is a misdemeanor, punishable by up to six months
in a county jail, by a fine of one thousand dollars ($1,000), or by both that imprisonment and fine. For further
details about these requirements, refer to Penal Code section 11164 and Welfare and Institutions Code
section 15630 and following sections.
APPLICANT AFFIDAVIT
(must be signed and dated by the applicant)
I, , hereby attest to the fact that I am the
(Print Full Legal Name)
applicant whose signature appears below. I hereby certify 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 this
application, including all supplementary statements. I understand that my application may be denied, or any
license disciplined, for fraud or misrepresentation.
Original Signature of Applicant Date
(please sign and date within 60 days of board receipt of the application)
17A-17 (1/2021) 5
□
__________________________________________________________________________________________
__________________________________________________________________________________________
____________________________________________________________________ _____________________
_____________________________________________________ ____________________________________
California State Board of Pharmacy
2720 Gateway Oaks Dr, Suite 100
Sacramento, CA 95833
Phone: (916) 518-3100 Fax: (916) 574-8618
www.pharmacy.ca.gov
Business, Consumer Services and Housing Agency
Department of Consumer Affairs
Gavin Newsom, Governor
INTERN PHARMACIST EDUCATION AFFIDAVIT
Instructions: This form must be completed by the dean of the school of pharmacy.
This is to certify that _________________________________________________________________________
Print Name of Applicant
who is applying to the California State Board of Pharmacy for an intern pharmacist license is: (check one)
____ Enrolled as a student in this institution and is seeking a degree in pharmacy.
____ Re-enrolled to take additional coursework prior to re-examination by the board.
Year enrolled in school ________________ Expected date of graduation________________
Month/Year Month/Year
I hereby certify as the dean of the school of pharmacy listed below or as a person with authority and personal
knowledge under penalty of perjury under the laws of the State of California to the truth and accuracy of the
above:
Signed: ________________________________________ Title: _______________________ Date: __________
College, University, or School of Pharmacy
Street Address City State Zip Code
Print Name of Dean or Person of Authority and Personal Knowledge of these Facts Title
Phone Number Email Address
Affix School Seal Here
17A-17 (1/2021) 6
_____________________ ________________ ____________ ______________ _______________________
__________________________________________________________________________________________
________________________________________________
________________________________________________
California State Board of Pharmacy
Business, Consumer Services and Housing Agency
2720 Gateway Oaks Drive, Suite 100
Department of Consumer Affairs
Sacramento, CA 95833
Gavin Newsom, Governor
Phone: (916) 518-3100 Fax: (916) 574-8618
www.pharmacy.ca.gov
VERIFICATION OF LICENSE IN ANOTHER STATE
This form must be completed by the licensing agency in each state you hold or held an individual license (e.g.
pharmacist, intern pharmacist, pharmacy technician, designated representative, and/or another healthcare
professional license) even if the license is no longer current or active. Please return the original state-verified
form with your application for each license type. Photocopies or faxes will not be accepted.
Intern hours and licensure earned in another state may be certified by the licensing agency in each state you
earned your intern hours or license on this form.
The licensee listed on this form has applied for a license in California. Before further consideration is given to
this application, the California State Board of Pharmacy would appreciate your assistance in completing the
information requested below. Upon completion of this form, please return it to the applicant for submission
with the application.
Completed by Licensee ___________________________________________________ __________________
Licensee’s Full Name License Number
Completed by the State Licensing Board or Agency Verifying Licensure
Licensure Verification License Type and Issued Date Expiration Date Intern Hours Earned in this
Provided by the State of License Number State under this Intern
License
License Status (Please check one) – Active _______ Inactive _______ Other _________ If other, please explain
Has this agency taken any disciplinary action against this license? Yes ______ No ______
If disciplinary action has been taken against this licensee, please directly provide this office with the
accusation/proposed charges and decision/final order regarding the action.
I hereby certify the information listed above is true and
correct.
Printed Name
Board Seal ________________________________________________
Signature
Title Date
17A-16 (2/2019)
INSTRUCTIONS FOR COMPLETING A
"REQUEST FOR LIVE SCAN SERVICE" FORM
California Live Scan
The following instructions are provided to assist you in completing this form accurately. Please
follow all instructions carefully and print clearly.
NOTE TO APPLICANT/LICENSEE and LIVE SCAN OPERATOR: The name, date of birth and US
Social
Security Number (SSN) must be entered in at the time of the Live Scan transmission for the
results to be accepted by the California State Board of Pharmacy. If the name, date of birth or
SSN is not entered at the time of Live Scan transmission, the individual may have to have a new
Live Scan transmission completed.
Type of License/Certification or Permit or Working Title: The Live Scan operator must enter in
the Type of License that is specified on the Request for Live Scan Service form.
Applicant Information:
Name: Enter your last name, first name and middle name that matches your
government issued driver’s license or state identification. Do not use initials or name
abbreviations. Your legal name must be on file with the board. If your name has
changed you are required to notify the board within 30 days of the change.
Other Name (AKA): Enter all other names you have used, including your maiden name.
Date of Birth: (month/day/year).
SEX: Mark the appropriate gender box (male or female)
Driver’s License Number: Driver’s License Number.
Height: Your height in feet and inches.
Weight: Your weight in pounds.
Eye Color: Color of your eyes
Hair Color: Color of your hair
Place of Birth: Enter your place of birth
Social Security Number: Must be included and be correct, unless you have an ITIN. If
you have an ITIN, then this field should be left blank.
Misc. Number: Other identification number
Home Address: Your residence address
Level of Service: This has already been preselected for you. You are required to have both DOJ
and FBI level of service complete. Please ensure at the time of Live Scan transmission that the
Live Scan operator selects both the DOJ and FBI levels of service in their computer system. If FBI
is not selected at the time of original transmission, you will be required to have your Live Scan
redone at another time and repay for the DOJ and FBI levels of services again. The board has
been notified by the DOJ that effective 9/1/07, if the FBI level of service is not requested at the
time of original transmission both DOJ and FBI levels of service will have to be redone. Any
issue of cost for resubmission should be handled at the Live Scan Site level.
Employer: This information is not required.
Take the completed form to your nearest Live Scan site for fingerprint scanning. There are
more than 130 Live Scan sites throughout the state. An up-to-date Live Scan site list is on the
Department of Justice's (DOJ) Internet web page at https://oag.ca.gov/fingerprints/locations or
call your local police or sheriff's department.
Contact the live scan service for hours of operation, an appointment (if necessary), acceptable
forms of payment and identification requirements. Be prepared to pay ALL applicable fees (DOJ
processing fee of $32, FBI processing fee of $17, and fingerprint scanning service fee) at the
time your prints are taken. The live scan fingerprinting service fee varies from about $5 to $20.
The cost to electronically submit your fingerprints is determined by the local Live Scan agency
and the agency can charge a fee sufficient to recover its costs. The lower portion of the Request
for Live Scan Service form must be completed by the live scan operator. The original of the form
is retained by the scanning service; the second copy is to be attached to your application and
submitted to the board; and the third copy is for your records.
FINGERPRINTING AUTHORITY
Section 144(b) of the Business and Professions Code authorizes the Board of Pharmacy to
require an applicant for licensure to furnish a full set of fingerprints for purposes of conducting
criminal history record checks. Fingerprints are required for the DOJ/FBI to conduct background
checks for criminal convictions.
STATE OF CALIFORNIA DEPARTMENT OF JUSTICE
BCII 8016
(orig. 4/01; rev. 6/09)
REQUEST FOR LIVE SCAN SERVICE
Applicant Submission
ORI (Code assigned by DOJ)
Authorized Applicant Type
Type of License/Certification/Permit OR Working Title (Maximum 30 characters - if assigned by DOJ, use exact title assigned)
Contributing Agency Information:
Agency Authorized to Receive Criminal Record Information Mail Code (five-digit code assigned by DOJ)
Street Address or P.O. Box Contact Name (mandatory for all school submissions)
City State ZIP Code
Contact Telephone Number
Applicant Information: Live Scan Operator – The Board of Pharmacy requires you to enter the applicant’s SSN.
Last Name First Name Middle Initial Suffix
Other Name
(AKA or Alias)
Last First Suffix
Male Female
Sex
Date of Birth Driver's License Number
Billing
Height Weight Eye Color
Hair Color
Number
(Agency Billing Number)
Misc.
Place of Birth (State or Country)
Social Security Number - MANDATORY
Number
(Other Identification Number)
Home
Address
Street Address or P.O. Box City State ZIP Code
DOJ FBI
Level of Service:
Your Number:
OCA Number (Agency Identifying Number)
If re-submission, list original ATI number:
Original ATI Number
(Must provide proof of rejection)
Employer (Additional response for agencies specified by statute):
Employer Name Mail Code (five digit code assigned by DOJ
Street Address or P.O. Box
City State ZIP Code
Telephone Number (optional)
Live Scan Transaction Completed By:
Name of Operator Date
Transmitting Agency LSID ATI Number Amount Collected/Billed
ORIGINAL - Live Scan Operator SECOND COPY - Applicant THIRD COPY (if needed) - Requesting Agency
Print Form
Reset Form
A0071
License/Cert/Permit
Pharmacy Intern - Section 4114
Board of Pharmacy
05712
2720 Gateway Oaks Drive, Suite 100
Licensing
Sacramento
CA
95833
9165183100
N/A
N/A
N/A
N/A
N/A
N/A
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

INTERN PHARMACIST APPLICATION INSTRUCTIONS (California)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 30 June 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document