California Retake Form – Fill Out and Use This PDF

	California State Board of Pharmacy	BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY
1625 N. Market Blvd, Suite N219, Sacramento, CA 95834		DEPARTMENT OF CONSUMER AFFAIRS
Phone (916) 574-7900		GOVERNOR EDMUND G. BROWN JR.
Fax (916) 574-8618
www.pharmacy.ca.gov

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.

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

1.	Have you ever been expelled from a pharmacist licensure exam administered in this state or any other state?			Yes	No
	If “yes,” provide the date and state. ___________________________________
2.	Have you previously taken a pharmacist exam which was not graded or had exam results			Yes	No
	withheld on grounds of dishonest conduct during an examination in this state or any other state?
	If “yes,” provide the date and state. _________________________________________
3.	Do you have a medical condition which in any way impairs or limits your ability to practice your profession			Yes	No
	with reasonable skill and safety without exposing others to significant health or safety risks?
	If “yes,” attach a statement of explanation. If “no,” proceed to #4.
	Are the limitations caused by your medical condition reduced or improved because you receive ongoing
	treatment or participate in a monitoring program?	Yes	No
	If “yes,” attach a statement of explanation.
	If you do receive ongoing treatment or participate in a monitoring program, the board will make an
	individualized assessment of the nature, the severity and the duration of the risks associated with an ongoing
	medical condition to determine whether an unrestricted license should be issued, whether conditions should
	be imposed, or whether you are not eligible for licensure.
4.	Do you currently engage, or have you been engaged in the past two years, in the illegal use of controlled			Yes	No
	substances?
	If “yes,” are you currently participating in a supervised rehabilitation program or professional assistance
	program which monitors you in order to assure that you are not engaging in the illegal use of controlled
	substances?	Yes	No
	Attach a statement of explanation.
5.	Has disciplinary action ever been taken against your pharmacist license, intern permit or technician			Yes	No
	registration in this state or any other state?
	If “yes,” attach a statement of explanation to include circumstances, type of action, date of action and
	type of license, registration or permit involved.
6.	Have you ever had an application for a pharmacist license, intern permit or technician registration denied in			Yes	No
	this state or any other state?
	If “yes,” attach a statement of explanation to include circumstances, type of action, date of action
	and type of license, registration or permit involved.
7.	Have you ever had a pharmacy permit, or any professional or vocational license or registration, denied or			Yes	No
	disciplined by a government authority in this state or any other state?
	If “yes,” provide the name of company, type of permit, type of action, year of action and state.
	______________________________________________________________
8.	Have you ever been convicted of any crime in any state, the USA and its territories, military court or foreign			Yes	No
	country?
	Check the box next to “YES” if, you have ever been convicted or plead guilty to any crime. “Conviction”
	includes a plea of no contest and any conviction that has been set aside or deferred pursuant to Sections
	1000 or 1203.4 of the Penal Code, including infractions, misdemeanor, and felonies. You do not need to
	report a conviction for an infraction with a fine of less than $300 unless the infraction involved alcohol or
	controlled substances. You must, however, disclose any convictions in which you entered a plea of no
	contest and any convictions that were subsequently set aside pursuant or deferred pursuant to sections 1000
	or 1203.4 of the Penal Code.
	Check the box next to “NO” if you have not been convicted of a crime.

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

	Arrest Date	Conviction Date		Violation(s)	Case #	Court of Jurisdiction (Full Name and Address)

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)

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)		3