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
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17A-7 (REV 6/2024)
PHARMACY TECHNICIAN APPLICATION INSTRUCTIONS
HOW LONG WILL IT TAKE TO PROCESS MY APPLICATION?
Allow the Board 30 days to process your application.
The Board will communicate via email regarding the status of your application. You will receive an
acknowledgement email within 15 days of receipt.
Once your application is reviewed, you will receive a “Deficiency Notice” via email 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.
Failure to complete your application within 60 days from the date the Board notifies you of the
deficiencies, may result in your application being considered abandoned and withdrawn.
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. 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
1. APPLICATION FEE IS $195:
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 A PHARMACY TECHNICIAN LICENSE (form 17A-5 (rev. 10/15): Complete the entire
application.
AVOID COMMON MISTAKES
• The name on each form must be EXACTLY THE SAME as the name on your state driver’s license or
state-issued identification card. Your name must be the same on each of the following documents:
Pharmacy Technician 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?
If you do not list all of your previous names, the board may not locate, match or verify your
documents.
• Do not leave anything blank; use “N/A” if a question doesn’t apply to you.
• Do not let your school fill out Pages 1, 2 and 3 of your application.
• You must sign and date the application. No one else can sign it for you. Signatures must be original and
dated within 60 days of filing the application. No electronic signatures will be accepted.
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3. U.S. Social Security Number (SSN) or Individual Taxpayer Identification Number (ITIN): Disclosure of your
U.S. social security number (SSN) or Individual Taxpayer Identification Number (ITIN) is mandatory and must
be included on the application and on the Self-Query Report.
4. PHOTO: Please attach a passport-style photo to page 1 of the application (2”x2” glossy color 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, C,
or D).
A. Active Duty Member Enrolled in SkillBridge Program: If you are an active duty member of a regular
component of the Armed Forces of the United States enrolled in the United States Department of
Defense SkillBridge program as authorized under Section 1143(e) of Title 10 of the United States Code,
please provide satisfactory evidence of your enrollment. (Check Military (Are you currently serving in
the United States military?) on page 1 of the application.
B. Serving in the Military: Are you currently serving in the United States military?
Attach a copy of your military identification.
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.
D. Military Veteran: Have you ever served in the United States military?
Please attach a copy of your DD214 with your application.
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.
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.
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• An order from a court of competent jurisdiction or other documentary evidence that provides
reasonable assurance that the applicant qualifies for expedited licensure.
BASIC EDUCATION: You must be a high school graduate or have a general education development certificate
equivalent.
Attach ONE of the following (A, B, C, D, or E):
A. U.S. High School Graduate: Attach an official, embossed transcript (academic record) or notarized copy
of your high school transcript. It must have the graduation date on it. To get a copy of your high school
transcript, contact your high school or its school district office.
B. Foreign High School Graduate: Attach a notarized copy of your foreign secondary school diploma or
certificate OR a notarized copy of your foreign secondary school transcripts. If not in English, then
include a certified translation in English. The translation may be from an evaluation service that states
your education is equal to graduating high school in the U.S.
C. High School Equivalency: (Attach 1, 2, or 3 to show documentation of completing one of the three High
School Equivalency Tests.)
1. General Educational Development (GED): Attach an official transcript of your test results or
equivalent. GED test results are official only if they are earned through an authorized GED Testing
Center. To get your GED transcripts, go to http://www.gedtestingservice.com/testers/gedrequest-
a-transcript. If your GED is from another state, you may need to request an official transcript of
your GED test results from the agency in that state.
2. HiSET: Attach an official transcript of your test results or equivalent. HiSET test results are official
if they are earned through an authorized HiSET Testing Center. To request your HiSET transcripts,
go to www.diplomasender.com.
3. TASC: Attach an official transcript of your test results or equivalent. TASC test results are official if
they are earned through an authorized TASC Testing Center. To request your TASC transcripts, go
to http://www.tasctest.com/.
D. Certificate Equivalent – Attach an official “Certificate of Proficiency” showing you passed the California
High School Proficiency Examination (CHSPE). To request a copy, go to https://www.chspe.net/cert-
trans/ or call (866) 342-4773.
E. Out-of-State High School General Educational Development Certificate Equivalent: Attach an official
transcript of your test results or equivalent.
7. PHARMACY TECHNICIAN DOCUMENTS: Attach ONE of the following (A, B, C, or D):
A. Affidavit of Completed Coursework or Graduation for Pharmacy Technician (17A-5 rev 10/15): The
program director, school registrar or pharmacist must complete and sign the affidavit on Page 4. Copies
or stamped signatures are not accepted. The school seal must be embossed on the affidavit and/or you
must attach a pharmacist’s business card with license number. An affidavit is required for one of the
following:
• Associate Degree in Pharmacy Technology;
• Any other course that provides a training period of at least 240 hours of instruction as specified in
Title 16 California Code of Regulation section 1793.6(c);
• Training course accredited by the American Society of Health-System Pharmacists (ASHP);
• Graduation from a school of pharmacy accredited by the Accreditation Council for Pharmacy
Education (ACPE).
B. Pharmacy Technician Certification Board (PTCB) certified: Submit a copy of your PTCB certificate.
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C. National Healthcare Association Pharmacy Technician Certification Program (ExCPT): Submit a copy of
your ExCPT certificate. Effective January 1, 2017, the Board will accept ExCPT certifications dated On or
After January 1, 2017. ExCPT certifications received prior to January 1, 2017 will not be accepted.
Please check the box on the application on page 1 under the Pharmacy Technician Qualifying Method
“Attached is a certified copy of PTCB certificate program”. By checking this box this will identify your
application as applying under a certification program.
D. Military Training: Submit a copy of your DD214 documenting evidence of your pharmacy technician
training provided by a branch of the federal armed services.
8. 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.
• You must include your US social security or ITIN number when completing 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 is 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.
9. 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 your application.
• You must submit a copy of your Live Scan receipt or new 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 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. You must be sure everything on the form is correct.
Make sure the following information is correct when you complete your Live Scan:
• Type of License/Certification/Permit or Working Title: Pharmacy Tech-Sect 4015
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• Full Name: Must be EXACTLY THE SAME as the name on your state 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 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, enter this number in the SSN field.
• 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 send two rolled fingerprint cards.
• 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 [email protected].
• 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.
• 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.
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
PHARMACY TECHNICIAN APPLICATION
lease read the application instructions before you complete the application. Failure to provide the requested
information may result in the application being considered incomplete.
Attach additional sheets on paper if necessary.
_____ Military (Are you currently serving in the United States military?)
_____ Veteran (Have you ever served in the United States military?)
MILITARY EXPEDITE (Please check one of the following, if applicable)
______Veteran (Have you served as an active duty member of the United States
military and been honorably discharged?)
______Active Duty Military Spouse or Domestic Partner (Are you married to, or in a
domestic partnership or other legal union with, an active duty member of the
United States military who is assigned to a duty station in California under
official active duty military orders and do you hold a current license in another
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
state, district, or territory of the United States in the profession for which you seek licensure?)
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 First Name Middle Name
__________________________________________________________________________________________
Previous Names (AKA, Maiden Name, Alias, etc.)
__________________________________________________________________________________________
*Official Mailing/Public Address of Record (Street Address, PO Box#, etc.) City State Zip Code
_________________________________________
Home #
Cell #
Issuance CASHIERING ONLY
License #
APPLICATION FEE
App Fee: ____
Enf. Check: ___
Photo: ___
Qualify Code: ____
School Code: _____
FP Card/Fee: ___
LS: ___
DOJ Date______
FBI Date ______
Self-Query: ____
Date Issued
Receipt #:
Date Expires
Date Cashiered:
Amount:
17A-5 (Rev. 12/2021) 1
Work #
_______________________________________
Driver’s License Number State
_________________________________
Date of Birth (Month/Day/Year)
Email Address
______________________________________
____________
**US Social Security # or Individual Tax ID #
THIS SECTION IS FOR BOARD USE ONLY
__________________________________________________________________________________________
Residence Address (If different from above) Street
City
State Zip Code
_____________________________
_____________________
_______________________________
Mandatory Education
Please indicate how you satisfy the education requirement in Business and Professions Code section 4202(a).
_____ United States High
school
graduate.
Attach
an
official
embossed
transcript
or
notarized
copy
of
your
high
school
transcript,
or
certificate
of proficiency.
_____ Foreign Equivalent to United State
s High School
Attach a notarized
copy
of your
foreign secondary
school
transcript
or diploma along with a certified
translation
of the
document
if
it is
not in
English.
_____ Completed a general education development certificate equivalent.
Attach an official transcript in a sealed envelope or notarized copy
of your test results or certificate of
proficiency
.
Pharmacy Technician Qualifying Method (check one box)
Please check one of the boxes below indicating how you qualify in order to apply for a pharmacy technician
license pursuant to section 4202(a)(1) through (4) of the Business and Professions Code.
_____ Attached is the Affidavit of Completed Coursework or Graduation for: Associate degree in Pharmacy
Technology, Training Course, or Graduate of a school of pharmacy
_____ Attached is a copy of PTCB or ExCPT certificate
_____ Attached is a copy of military training DD214
List all state(s) where you hold or held a license as a pharmacy technician, pharmacist, intern pharmacist
and/or another health care professional license, including California. Attach an additional sheet if
necessary.
State Registration Number Active
or Inactive Issued Date Expiration Date
______ ___________________________ __________________ ____________ _______________________
______ ___________________________ __________________ ____________ _______________________
Self-Query Report by the National Practitioner Data Bank (NPDB)
_____ Attached is the original sealed envelope containing my Self-Query Report from NPDB. (This must be
submitted with your application in a sealed envelope.)
APPLICANTS MUST ANSWER THE FOLLOWING QUESTIONS.
Ownership Information - For any affirmative answer, 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.
1. 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.
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2.
3.
4.
5.
6.
7.
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.
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____ If “yes,” attach a statement of explanation.
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____ If “yes,” attach a statement of explanation.
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?
Yes ____ No____ If “yes,” attach a statement of explanation.
Practice Impairment or Limitation
The board will make 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.
Do you have an emotional, mental, or behavioral disorder that may impair your ability to practice safely?
Yes ____ No____ If “yes,” attach a statement of explanation.
Do you have a physical condition that may impair your ability to practice safely?
Yes ____ No____ If “yes,” attach a statement of explanation.
Do you have any other condition that may in any way impair or limit your ability to practice safety?
Yes ____ No____ If “yes,” attach a statement of explanation.
Have you participated in, been enrolled in, or required to enter into any drug, alcohol, or other substance
abuse recovery program?
Yes ____ No____ If "yes," attach a statement of explanation.
If you answered "Yes" to questions 5 through 8 above, have you 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.
Professions Code Sections 30 and Chapter 9 and California Code of Regulations title 16, division 17. The
California State Board of Pharmacy uses this information principally to identify and evaluate applicants
17A-5 (Rev. 12/2021) 3
8.
9.
Provide a written explanation for all affirmative answers. Failure to do so may result in this application
being deemed incomplete. Falsification of the information on this application may constitute ground
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 may result in the application being deemed as incomplete and a deficiency notice
being issued. An applicant who fails to complete all application requirements within 60 days
after being notified by the board of deficiencies in his or her file may be deemed to have abandoned the
application and may be required to file a new application, fee (as required by 16 CCR section 1749), and
meet all the requirements in effect at the time of reapplication. for licensure, issue and renew licenses,
and enforce licensing standards set by law and regulation.
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 Chapter 9 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 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 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 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 number or individual taxpayer identification 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 number or individual taxpayer
identification number. Your social security number or individual taxplayer 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.
17A-5 (Rev. 12/2021) 4
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 applications 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 the licensee's professional capacity or within the scope of the licensee's 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
reportermust contact by telephone immediately or as soon as possible, to make a report to the appropriate
agency(ies) or as soon as 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. Must be received by the Board within 60 days)
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.
___________________
Date
_______________________________________________________________
Original Signature of Applicant
(please sign and date within 60 days of board receipt of the application)
17A-5 (Rev. 12/2021) 5
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
AFFIDAVIT OF COMPLETED COURSEWORK OR GRADUATION FOR PHARMACY TECHNICIAN
Instructions: The Director, Registrar, or Pharmacist must complete and sign this form certifying the
identified individual has met the specified requirements in section 4202 of the Business and Professions
Code and, if applicable, board regulations. All dates must include the month, day, and year for the form to
be accepted.
This is to certify that __________________________________________________________________ has
Print Full Name of Applicant
_____ Completed a pharmacy technician training program accredited by the American Society of Health-
System Pharmacists (ASHP) as specified in Title 16, California Code of Regulations section
1793.6(a) on __________/________/__________
(completion date must be included)
_____ Completed a training course that provided at least 240 hours of instruction as specified in Title 16,
California Code of Regulations Section1793.6(c) on __________/________/__________
(completion date must be included)
_____ Completed an Associate Degree in Pharmacy Technology and was conferred on
__________/________/__________
(graduation date must be included)
_____ Graduated from a school of pharmacy accredited or granted candidate status by the Accreditation
Council for Pharmacy Education (ACPE). The degree of Bachelor of Science in Pharmacy or the
degree of PharmD was conferred on __________/________/__________
(graduation date must be included)
I hereby certify under penalty of perjury under the laws of the State of California to the truth and accuracy of the
above:
Signed ___________________________ Title _______________________ Date_________________________
Name of Pharmacy Technician Training Program, Course or School of Pharmacy _____________________________
Address____________________________________________________ Phone Number _______________________
Print Name of Director, Registrar, or Pharmacist ________________________________________________________
Email ___________________________________ Pharmacy/Pharmacist License Number ______________________
Affix school seal here or Attach a business card of the pharmacist who provided the training pursuant to section
1793.6(c) of Title 16, California Code of Regulations here. The pharmacist’s license
number shall be listed.
17A-5 (Rev. 12/2021) 6
INSTRUCTIONS FOR COMPLETING A
"REQUEST FOR LIVE SCAN SERVICE" FORM
California Residents
The following instructions are provided to assist you in completing this form accurately. Please follow all
instructions carefully and print clearly.
NOTE TO LICENSEE and LIVE SCAN OPERATOR: The name, date of birth and US Social
Security Number (SSN) or Individual Taxpayer Identification Number (ITIN) must be entered in at the time of
the Live Scan transmission in order for the results to be accepted by the Board of Pharmacy. If the name, date
of birth or SSN or ITIN is not entered at the time of Live Scan transmission, the licensee 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 your type of
license. Please have the Live Scan operator enter in in the Type of License listed on the Live Scan Form.
Applicant Information:
Name: Enter your last name, first name and middle name. 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: California 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, enter this number in the SSN field.
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 may be required to have your Live Scan redone at another time and have to 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 $19, 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 in order 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 Tech- Section 4015
Board of Pharmacy
05712
2720 Gateway Oaks Drive, Suite 100
Licensing
Sacramento
CA
95833
9165183100
Applicant Must Pay Fees
N/A
N/A
N/A
N/A
N/A
N/A
