Fillable Printable Tch Online Renewal Form (1 16)

Tch Online Renewal Form (1 16)

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.

Request for Renewal of Pharmacy Technician License

Complete the form below and submit a check or money order made payable to the Board of Pharmac y no more than 60 days before the

expiration date of the license. Fees submitted more than 60 days before the expiration date will be return ed.

Renewal Fees: $130, if submitting before the e xpir ation date, or

Renewal plus Delinquency Fees:

$195 ($130 renewal fee plus $65 delinquency fee) if the license has expired.

INSTRUCTIONS: Check the box to “YES” if, since your last renewal, you have had any license disciplined by a government agency or have

you been convicted or plead guilty to any crime. “Conviction” includes a plea of no conte s t 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 felo nies. 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 1210.1 or 1203.4 of the Penal Code. “Lice nse” includes permits, registrations, and certificates. “Discipline” includes,

but is not limited to, suspension, revocation, voluntary surrender, probatio n, or any other restriction.

Check the box next to “NO” if since your last renewal you have not had a license disciplined by another government agency and you have not

been convicted of a crime.

Mail the renewal form and payment to:

California State Board of Pharmacy, 1625 N. Market Blvd. N219, Sacramento, CA 95834

*Your address of reco rd with the board is considered public information pursuant to the Information Practices Ace (Civil Code

section 1798 et seq.) and the Public Records Act (Government Code section 6250 et seq.) and will be placed on the Internet. If you

do not wish your residence address to be available to the public, you may provide another address but you must also p rovide your

residence address as an alternate address th at will not be available to the public.

All items of information requested are mandatory. Failure to provide any of the information will result in the request for renewal being

rejected as incomplete. The information will be used to determine qualifications for licensure under the California Phar macy Law. The official

responsible for information maintenance is the Executive Officer, telephone (916) 574-7900, 1625 N. Market Blvd. N219, Sacramento,

California 95834. The information may be transferred to another governmental agency such as a law enforcement agency if necessary for it

to perform its duties. Each individual has the right to review the files or records maintained on them by our agency, unless the records are

identified as confidential information and exempted by Section 1798.40 of the Civil Code.

NOTICE: Effective July 1, 2012, the State Board of Equalization and the Franchise Tax Board ma y share taxpayer information with the board.

You are obligated to pa y your state tax obli gation. This application may b e 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 sections 11164 and Welfare and Institutions Code section 15630, and subsequent sections.

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Request for Renewal of Pharmacy Technician MILITARY (Are you serving in the United States military?)

VETERAN (Have you ever served in the United States military?)

Name: License Number: Expire Date:

*Previous Address of Record: Number and Street City, State, Zip

*Current Address of Record: Number and Street City, State, Zip

Residence Address: (if different from above) City, State, Zip

Telephone Number: Email address: Date of Birth

Since you last renewed y our license, have you had any license disciplined by a government agency or other disciplinary body; or, have you been

convicted of any crime in any state, the USA and its territories, military court or a foreign countr y? PLEASE READ INSTRUCTIONS BEFO RE

ANSWERING. YES NO

I declare under penalty of perjury under the laws of the state of California that the foregoing is true and correct.

Signature: Date:

Rev (1.16)