Blank California Retake PDF Form

RETAKE APPLICATION INSTRUCTIONS

APPLICATION PROCESSING TIMEFRAME

Please allow the board 30 days to process your application. The board will mail you either your eligibility letter to sit for the examination(s) or a deficiency letter if your application is incomplete.

Due to current workload the board will not be able to respond to status checks on your application unless your application has been on file for over 60 days.

Once you have completed your requirements for licensure (passing both NAPLEX and CPJE) and your bank has processed your initial license fee check, an easy way to verify if the board has issued you a license is to visit the board’s website at www.pharmacy.ca.gov under “Verify a License”, as the processing time to receive your pharmacist wallet license is 4-6 weeks from the date the license is issued.

APPLICATION INSTRUCTIONS

Print out the entire application and required forms as instructed under What Makes an Application Complete in these instructions. Please include all the required forms prior to submitting your application to the board.

PLEASE NOTE: It is very important that when you complete the application, the name you apply under IDENTICALLY matches the name on your U.S. social security card and your U.S. government issued photo identification (state issued driver’s license or state issued identification card).

FULL LEGAL NAME

It is very important that you complete your application by applying under your full legal name. Your full legal name on record with the board is the name you submit with your pharmacist licensure examination application. The board will make you eligible only under your name on record with the board and not aliases.

In order to be admitted to take the CPJE, you will need to be prepared to display at the testing site your U.S. social security card AND U.S. government issued photo identification. Your name on both forms of identification must match letter for letter with the name of record on file with the board (e.g., if your middle name is spelled out on your U.S. government issued photo identification, then your middle name must be spelled out on your U.S. social security card, and both of these identifications must match exactly to the name of record on file with the board.) The testing site will NOT allow you to sit for the CPJE without your identifications matching IDENTICALLY with your name of record on file with the board. Photocopies of your identifications will not be accepted at the testing site.

WHAT MAKES AN APPLICATION COMPLETE Before the board can classify you as eligible to take the NAPLEX and/or the CPJE, you must submit a fully completed “Retake Application” (form 17A-1A)” along with all other required documents and fees as instructed in this section. If you have requested a score transfer to California from NABP for the NAPLEX and you have sat for the NAPLEX more than once to obtain a passing score, you are required to submit a Retake Application for each NAPLEX score in order for California to request all your NAPLEX scores to be transferred by the NABP.

APPLICATION FEE: If you are submitting a Retake Application for the NAPLEX there is NO FEE. If you are applying to retake the CPJE, please submit a check, money order, or cashier’s check in the amount of $200, made payable to the Board of Pharmacy. The application fee is non-refundable. Please check the appropriate box on the application identifying the appropriate examination(s).

RETAKE APPLICATION: (form 17A-1A): The application must be completed in its entirety-- with all questions answered. Failure to do so will result in an incomplete application and a deficiency letter will be mailed to you. Failure to correct the deficiencies will result in your application being deemed abandoned.

ACTIVE DUTY MILITARY - Spouses or Partners Receive Expedited Review: The board is required to expedite the licensure process for an applicant whose spouse or partner is an active duty member of the U.S. Armed Forces and meets other criteria. (Business and Professions Code section 115.5.) If you would like to be considered for this expedited review and process, please provide the following required documentation.

1.Are you married to, or in a domestic partnership or other legal union with, an active duty member of the Armed Forces of the United States who is assigned to a duty station in California under official active duty military orders?

If “yes,” please attach a copy of the marriage certificate or certified declaration/registration of domestic partnership filed with the Secretary of State AND military orders establishing duty station in California. For other forms of “legal union” not recognized by California, you may submit other documentary evidence of legal union issued by the State that recognizes your legal union for consideration by the board in meeting this requirement.

2.Do you hold a current license in another state, district, or territory of the United States in the profession or vocation for which you seek licensure from the board?

If “yes,” please attach a copy of the current license in another state, district, or territory of the United States.

VERIFICATION OF LICENSE IN ANOTHER STATE: If you have been issued an intern pharmacist or pharmacist license in another state since you submitted your initial pharmacist examination and license application, you must request each state board or agency to verify your license on form 17A-16. You only need to submit one form 17A-16 per state.

PRACTITIONER SELF-QUERY REPORT: If you did not provide a sealed original Self-Query Report from the National Practitioner Data Bank Healthcare Integrity and Protection Data Bank ((NPDB-HIPDB) with your initial pharmacist examination and licensure application or it has been one year since you originally submitted a sealed original Self-Query Report, you are required to submit a sealed original Self-Query Report with this Retake Application. It is your responsibility to attach the sealed original NPDB-HIPDB Self-Query Report to your application.

The instructions to request a Self-Query Report are available at NPDB-HIPDB’s website: www.npdb- hipdb.hrsa.gov. The website includes a Fact Sheet on self-querying, as well as Frequently Asked Questions to assist you in requesting a report.

•Practitioner Self-Query Report requests are required to be submitted through the NPDB- HIPDB web site http://www.hpdb-hipdb.hrsa.gov. NPDB-HIPDB provides a toll-free number for individuals who do not have access to the Internet.

•Practitioners are required to pay a total charge of $16.00 directly to NPDB-HIPDB.

•Practitioners are required to mail to NPDB-HIPDB a notarized copy of the Self-Query request to a specified address. This copy can be printed, which the practitioner prints out after filling the form out on-line.

•NPDB-HIPDB provides a dispute process for a practitioner that wish to submit a statement or dispute to a report.

•The board is unable to assist you with the Self-Query process. Please contact the NPDB-HIPDB Customer Service Center at: (800) 767-6732 – TDD (703) 802-9395.

MAKE TEST ARRANGEMENTS: Please follow the below instructions for each examination.

NAPLEX: Visit the National Association of Boards of Pharmacy (NABP) Web site at http://www.nabp.net/ for information on how to register for the North American Pharmacist Licensure Examination (NAPLEX). Download the NAPLEX/MPJE Bulletin (see the NABP Web site). You must register on-line and remit the $465 fee to the NABP. You may register with NABP simultaneously when submitted your pharmacist application to the board or after the board has determined you are eligible to take the pharmacist examinations. However, the NABP will not contact you until you have registered on-line and remitted the $465 fee to the NABP. Once the board has determined you are eligible and you have paid your fee to the NABP, the NABP will mail you an Authorization to Test form (ATT). At this point, you will be able to schedule the location, date and time for your NAPLEX exam. Requirements and specifications for the NAPLEX are available in the NAPLEX/MPJE Bulletin. Additionally, there is a preNAPLEX test you may take as well to prepare you for the NAPLEX. If you have already taken and passed the NAPLEX, information on how to request a Score Transfer through NABP is on their Web site.

CPJE: You will not schedule to sit for this examination until the board has made you eligible. Please allow up to 14 days after you receive the board’s notification that you are eligible for PSI to mail you a Candidate Handbook. The outside cover of the handbook is your “Notice of Eligibility.” Use the information in this handbook to contact PSI. If you do not receive the Candidate Informational Bulletin in the mail you can download the Candidate Information Bulletin from the board’s Web site. After you have paid PSI $33, you will be able to schedule an appointment to take the CPJE. Again, the board

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ALL APPLICANTS MUST ANSWER THE FOLLOWING QUESTIONS (Attach additional sheet of paper if necessary)

Please provide the following information in order to assist in the process of your application: 1) certified copies of the arresting agency report; 2) certified copies of the court documents; 3) and a descriptive explanation of the circumstances surrounding the conviction (i.e. dates and location of incident and all

circumstances surrounding the incident.) If documents were purged by the arresting agency and/or court, a letter of explanation from these agencies is required. Failure to disclose a disciplinary action or conviction may result in the license being denied or revoked for falsifying the application

You must provide a written explanation for all affirmative answers. Failure to do so will result in this application being deemed withdrawn or incomplete.

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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)

(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.