
APPLICANT AFFIDAVIT
You must provide a written explanation for all affirmative answers. Failure to do so will result in this application being deemed incomplete. Falsification of
the information on this application may constitute grounds for denial or revocation of the license.
All items of information requested in this application are mandatory. Failure to provide any of the requested information will result in the application being
rejected as incomplete.
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 as authorized by Business and Professions Code Sections 4200 and 4209 and Title 16 California Code of Regulations Section 1719-1720.1
and 1728. 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.
Mandatory Submission. Submission of the requested information is mandatory. The California State Board of Pharmacy cannot consider your application for
licensure or renewal unless you provide all of the requested information.
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 Civil Code Section 1798.40.
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 in 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 by state or federal law; or
• In response to a court or administrative order, a subpoena, or a search warrant.
*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 et seq.) and the Public Records Act (Government Code Section 6250 et seq.) and will be placed on the Internet. This is where the board
will mail all 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.
** Disclosure of your U.S. social security account number 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 account number. Your social security account 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 account 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: Effective July 1, 2012, 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 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 Section 11164 and Welfare and Institutions Code Section 15630, and subsequent sections.
APPLICANT AFFIDAVIT
(must be signed and dated by the applicant)
I, , hereby attest to the fact that I am the applicant whose signature appears
(Print full name)
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 also certify that I have read the instructions attached to this application.
Signature of Applicant Date
17A-1A (1.13)
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