Fillable Renewal Application of a California Pharmacy Technician License (California)

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Renewal Application of a California Pharmacy Technician License (California)

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California State Board of Pharmacy
2720 Gateway Oaks Drive, 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
Renewal Application of a California Pharmacy Technician License
Complete the renewal application form and submit a check or money order made payable to the California State
Board
of Pharmacy. Failure to complete the renewal application in its entirety may result in the license not being
considered for renewal. The information will be used to determine qualifications for licensure under the California
Pharmacy Law. Failure to renew the license within 60 days after its expiration date, the license will be cancelled.
(Business and Professions Code section 4402(e)). Once the license is cancelled, you must file a new application
and meet all the requirements in effect at the time of reapplication.
Renewal Fees: $195, if submitting before the expiration date, or
Renewal plus Delinquency Fees: $292.50 ($195 renewal fee plus $97.50 delinquency fee) if the license has
expired.
Mail
the renewal form and payment to:
California State Board of Pharmacy, 2720 Gateway Oaks Drive, Sacramento, CA 95833
RENEWAL APPLICATION INSTRUCTIONS
1. Check the box “YES” if, since your last renewal, you have had any disciplinary action against any license
issued by a government agency or if you have been convicted as defined in Section 490 of the Business and
Professions Code, or any violation of the law in this or any other state, the United States, or other country.
Traffic infractions not involving alcohol, dangerous drugs, or controlled substances do not need to be
disclosed. For the purposes of this section, “disciplinary action” means an adverse licensure or certification
action that resulted in a restriction or penalty being placed on the license, such as revocation, suspension,
probation or public reprimand or reproval.
Check the box “NO” if, since your last renewal, you have not had a license disciplined by another
government agency and you have not been convicted as defined in Section 490 of the Business and
Professions Code, or any violation of the law in this or any other state, the United States, or other country.
Address of Record: A licensee’s address of record with the board is considered public information and will be
posted on the board’s website (Information Practices Act (Civil Code section 1798 et seq.) and the Public
Records Act (Government Code section 6250 et seq.)). You are also required to provide your residence address.
Email Requirement: Any individual licensed by the board is required to join the board’s email notification list
within 60 days of the issuance of a license or at the time of license renewal. The licensee must also update the
email address with the board’s list 30 days of a change (Business and Professions Code section 4013). You must
join the board’s email notification list from the board’s website at www.pharmacy.ca.gov.
Reporting Name and/or Address Changes
California law requires that you notify the Board of Pharmacy within 30 days of any change in name or address.
The board has specific requirements for documenting and reporting such changes. Please download this
information from the website at www.pharmacy.ca.gov (“Licensees” tab).
Rev (1/2020)
California State Board of Pharmacy
2720 Gateway Oaks Drive, 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
Failure to renew a pharmacy technician license within sixty days from the expiration date, will result in the
license being canceled pursuant to Business and Professions Code section 4402(e). If your pharmacy technician
license is canceled, you will be required to meet all licensure requirements in effect at the time of reapplication.
NOTICE: The State Board of Equalization and the Franchise Tax Board may share individual 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 the state tax obligation is not paid.
Mandatory Reporter
Under California law each person licensed by the Board of Pharmacy is a “mandated reporter” for both child and
elder abuse or neglect purposes. 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 Section 11166 and Section 15630 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, consult Penal Code sections 11164 and
Welfare and Institutions Code section 15630, and subsequent sections.
Rev (1/2020)
___________________________________________________ _________________ ____________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
California State Board of Pharmacy
2720 Gateway Oaks Drive, 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
Renewal Application of a California Pharmacy Technician License
___ MILITARY (Are you serving in the United States military?)
___ VETERAN (Have you ever served in the United States military?)
Name License Number Expiration Date
* Previous Address of Record City State Zip Code
* Current Address of Record City State Zip Code
* Residence Address (if different from above) City State Zip Code
Telephone Number Email Address Date of Birth
PLEASE READ THE INSTRUCTIONS BEFORE ANSWERING
1. Since your last renewal, have you had any disciplinary action against any license issued by a government
agency or have you been convicted as defined in Section 490 of the Business and Professions Code, or any
violation of the law in this or any other state, the United States, or other country. ___Yes ___ No
I declare under penalty of perjury under the laws of the State of California that the foregoing is true
and correct.
Signature:_______________________________________________________Date:______________________
Failure to complete the renewal application in its entirety may result in the license not being considered for
renewal. The information will be used to determine qualifications for licensure under the California Pharmacy
Law. The official responsible for information maintenance is the Executive Officer, telephone (916) 518-3100,
2720 Gateway Oaks Drive, Sacramento, CA 95833. The information may be transferred to another
governmental agency such as a law enforcement agency if necessary for it to perform its duties. An individual
has the right to review the files or records maintained on them by our agency, unless the records are
identified as confidential information and exempted by Section 1798.40 of the Civil Code.
Rev (1/2020)
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Completed 29 November 2021

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