Fillable Printable Pharmacy Technician Application Instructions - California
Fillable Printable Pharmacy Technician Application Instructions - California
Pharmacy Technician Application Instructions - California
California State Board of Pharmacy
1625 N. Market Blvd, N219, Sacramento, CA 95834
Phone: (916) 574-7900
Fax: (916) 574-8618
www.pharmacy.ca.gov
BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY
DEPARTMENT OF CONSUMER AFFAIRS
GOVERNOR EDMUND G. BROWN JR.
PHARMACY TECHNICIAN
APPLICATION INSTRUCTIONS
HOW LONG WILL IT TAKE?
It takes the board 45 days to process your application.
Y
ou will be notified by mail if your application is not complete.
P
lease do not contact the board to check on your application unless it has been on file for over 60
day
s.
If
your check has cleared your bank, the board has received your application.
T
o check if your license was issued, go to www.pharmacy.ca.gov. Select “Verify a License” and
ent
er your name. It takes four to six
weeks from the date a license is issued to receive the
license
in the mail.
WHAT MAKES AN APPLICATION COMPLETE?
Check the boxes below to be sure your application is complete before mailing it.
•
If your application is not complete, you will receive a “Deficiency Notice” in the mail.
•
You will then have 60 days to submit the required item(s).
•
If you do not submit the required item(s) within 60 days, you may have to file a new
application with new fees and meet any new requirements.
APPLICATION FEE $105: When you send your application, include a check or money order for
$105 made payable to the Board of Pharmacy. This fee is not refundable.
APPLICATION FOR A PHARMACY TECHNICIAN LICENSE (form 17A-5 (rev. 01/11): 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.
PHOTO:
Attach a passport-style, glossy, color photo (2”x2”) taken within 60 days of mailing the
application. DO NOT provide scanned images, Polaroids, or black-and-white photos.
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17A-7 (REV 5.15)
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.
•
To request a Self-Query Report, go to http://www.npdb.hrsa.gov or call (800) 767-6732
or TDD (703) 802-9395. Their website has a fact sheet and answers to frequently asked
questions. The board is not able help you get the Self-Query Report. For help, contact
NPDB directly.
•
You must pay the fee directly to NPDB. The fee is $8.
BASIC EDUCATION: You must be a high school graduate or have a General Education Degree
certificate equivalent.
Attach ONE of the following (A, B, C, or D):
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. 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
.
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.
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
PHARMACY TECHNICIAN DOCUMENTS:
Attach ONE of the following (A, B or C):
A.
Affidavit of Completed Coursework or Graduation: 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 minimum of 240 hours of instruction as required;
•
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.
C.
Military Training: Submit a copy of your DD214 documenting evidence of your pharmacy
technician training provided by a branch of the federal armed services.
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17A-7 (REV 5.15)
http://www.gedtestingservice.com/testers/gedrequest-a-transcript
https://www.chspe.net/cert-trans/ or call (866) 342-4773.
FINGERPRINTS:
•
California residents must use Live Scan. Non-residents can visit California to complete a
Live Scan or must submit professionally rolled fingerprints on cards supplied by the
board.
•
DO NOT complete the Live Scan service or fingerprint cards until you are ready to send
your application.
•
You must submit a new Live Scan receipt or new fingerprint cards with the application,
even if those were submitted to the board with other applications.
•
The Live Scan site may charge a processing fee.
•
The board will only accept fingerprint responses 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
•
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.
•
Level of Service: Must include both DOJ and FBI.
B. Non-California Resident:
You may visit California and complete Live Scan, but if you
cannot, then you must send rolled fingerprint cards.
•
You must use fingerprint cards from the B oard o f Pharmacy.
•
To get fingerprint cards, call (916) 574-7900 or email [email protected]a.gov
.
•
Fee:
Include
fingerprint card processing f
ee of $49
($32 DOJ and $17 FBI), made
payable to the Board of Pharmacy.
•
You can send one check or money order for $154 for both the application fee ($105) and
fingerprint processing fee ($49).
•
Fingerprints must be taken by a person professionally trained to roll prints.
•
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.
3 of 4
17A-7 (REV 5.15)
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.
MILITARY SPOUSES/PARTNERS (Check here if you are relocating to CA as a
result of your spouse’s/partner’s active duty military service.)
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.
If you answered “Yes” to these questions, please attach this document to the
front of your application when submitting it to the board. This will help staff
expedite your application.
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17A-7 (REV 5.15)
California State Board of Pharmacy
1625 N. Market Blvd., Suite N219, Sacramento, CA 95834
Phone (916) 574-7900
Fax (916) 574-8618
www.pharmacy.ca.gov
BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY
DEPARTMENT OF CONSUMER AFFAIRS
GOVERNOR EDMUND G. BROWN JR.
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.
MILITARY SPOUSES/PARTNERS (Check here if you are relocating to CA as a result of
your spouse’s/partner’s active duty military service.)
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.
Please attach this document to the front of your application if you answered “Yes” to
these questions when submitting your application to the board. This will assist staff to
expedite your application.
California State Board of Pharmacy
1625 N. Market Blvd, N219, Sacramento, CA 95 834
Phone: (916) 574-7900
Fax: (916) 574-8618
www. pharmacy.ca.gov
BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY
DEPARTMENT OF CONSUMER AFFAIRS
GOVERNOR EDMUND G. BROWN JR.
PHARMACY TECHNICIAN APPLICATION
All items of information requested in this application are mandatory. Failure to provide any of the requested information will result
in an incomplete application and a deficiency letter being mailed to you. Please read all the instructions prior to completing this
application. Page 1, 2, and 3 of the application must be completed and signed by the applicant. All questions on this application
must be answered. If not applicable indicate N/A. Attach additional sheets on paper if necessary.
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
Residence Address (if different from above)
City State Zip Code
Home# Cell # Work# Email Address
Date of Birth (Month/Day/Year) **Social Security N o Driver’s License # State
Mandatory Education (check one box)
Please indicate how you satisfy the mandatory education requirement in Business and
Professions Code Section 4202(a).
High school graduate or foreign equivalent.
Attach a certified copy of your high school transcript, or certificate of proficiency, or
foreign secondary school diploma along with a certified translation of the diploma.
Completed a General Education Development (GED)
Attach an official transcript or your GED test results.
TAPE A COLOR PASSPORT STYLE
PHOTOGRAPH (2”X2”) TAKEN
WITHIN
60 DAYS OF THE FILING OF THIS
APPLICATION
NO POLAROID
OR
SCANNED IMAGES
PHOTO MUST BE ON PHOTO
QUALITY PAPER
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), (2), (3) or (4) of the Business and Professions Code or Title 16 California Code of Regulations Section 1793.6(a),
(b) or (c).
Attached Affidavit of Completed Coursework or Graduation for: Associate degree in Pharmacy Technology, Training Course,
or Graduate of a school of pharmacy
Attached is a certified copy of PTCB certificate – Date certified:
Attached is a copy of your military training DD214.
Self-Query Report by the National Practitioner Data Bank Healthcare Integrity and Protection Data Bank (NPDB-HIPDB)
Attached is the sealed envelope containing my Self-Query Report from the NPDB-HIPDB. (This must be submitted with your application.)
FOR BOARD USE ONLY
Photo FP Cards/Live Scan
Enf 1
st
Check
Enf 2
nd
Check
Qualify Code
HIPDB
FP Cards Sent
FP Fees
DOJ Clear Date:
FBI Clear Date:
License no.
Date issued
Date expires
App fee no.
Amount
Date cashiered
17A-5 (Rev. 01/11) Page 1 of 4
You must provide a written explanation for all affirmative answers indicated below. Failure to do so may result in this
application being deemed incomplete and being withdrawn.
1. Do you have a medical condition which in any way impairs or limits your ability to practice your profession
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 #2.
Are the limitations caused by your medical condition reduced or improved because you receive ongoing
treatment or participate in a monitoring program?
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 license.
Yes
Yes
No
No
2. Do you currently engage, or have you been engaged in the past two years, in the illegal use of controlled
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
dangerous substances? Yes No
Attach a statement of explanation.
Yes No
3. Has disciplinary action ever been taken against your pharmacist license, intern permit or technician
license 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.
Yes No
4. Have you ever had an application for a pharmacist license, intern permit or technician license denied 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.
Yes No
5. Have you ever had a pharmacy permit, or any professional or vocational license or registration, denied or
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.
Yes No
6. Are you currently or have you previously been listed as a corporate officer, partner, owner, manager,
member, administrator or medical director on a permit to conduct a pharmacy, wholesaler, medical device
retailer or any other entity licensed in this state or any other state? If yes, provide company name, type of
permit, permit number and state where licensed.
Yes No
7. Have you ever been convicted of any crime in any state, the USA and its territories, military court or
foreign 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
1210.1 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 on no
contest and any convictions that were subsequently set aside pursuant or deferred pursuant to sections
1210.1 or 1203.4 of the Penal Code.
Check the box next to “NO” if you have not been convicted of a crime.
You may wish to provide the following information in order to assist in the processing of your application:
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. Attach additional sheets if necessary.
Arrest Date Conviction Date Violation(s) Court of Jurisdiction (Full Name and
Address)
Yes No
17A-5 (Rev. 01/11) Page 2 of 4
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 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
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 4202 and Title 16 California Code of Regulations Section 1793.5 and
1793.6. 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 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.
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 childe 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 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 Legal 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-5 (Rev. 01/11) Page 3 of 4
California State Board of Pharmacy
1625 N. Market Blvd, N219, Sacramento, CA 95 834
Phone: (916) 574-7900
Fax: (916) 574-8618
www.pharmacy.ca.gov
BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY
S
DEPARTMENT OF CONSUMER AFFAIRS
GOVERNOR EDMUND G. BROWN JR.
AFFIDAVIT OF COMPLETED COURSEWORK OR GRADUATION
FOR PHARMACY TECHNICIAN
Instructions: This form must be completed by the university, college, school, or pharmacist (The person who
must complete this form will depend on how the applicant is qualifying). All dates must include the month, day,
and year in order for the form to be accepted.
This is to certify that has
Print Name of Applicant
o
Completed a pharmacy technician training program accredited by the American Society of Health-System
Pharmacists as specified in Title 16 California Code of Regulations Section 1793.6(a) on
_____/_____/_____
(completion date must be included)
o
Completed 240 hours of instruction as specified in Title 16 California Code of Regulations Section 1793.6(c)
on _____/_____/_____
(completion date must be included)
o
Completed an Associate Degree in Pharmacy Technology and was conferred on her/him on
_____/_____/_____
(graduation date must be included)
o
Graduated from a school of pharmacy accredited by the American Council on Pharmaceutical Education
(ACPE). The degree of Bachelor of Science in Pharmacy or the degree of PharmD was conferred on
her/him 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: / /
Affix school seal here.
University, College,
or School of
Pharmacy Name:
Address:
OR
Attach a business card of the pharmacist
who provided the training pursuant to
Section 1793.6(c) of the California Code
of Regulation here.
Print Name of
Director, Registrar,
or Pharmacist:
Phone Number:
Email:
17A-5 (Rev. 01/11) Page 4 of 4
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
Other Name
(AKA or Alias)
Last
Sex
Male Female
Date of Birth
Height Weight Eye Color Hair Color
Place of Birth (State or Country)
Social Security Number - MANDATORY
Home
Address
Street Address or P.O. Box
First Name Middle Initial Suffix
First Suffix
Driver's License Number
Billing
Number
(Agency Billing Number)
Misc.
Number
(Other Identification Number)
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
