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California State Board Of Pharmacy

California State Board of Pharmacy

STATE AND CONSUMERS AFFAIRS AGENCY
1625 N. Market Blvd, Suite N219, Sacramento, CA 95834
DEPARTMENT OF CONSUMER AFFAIRS
Phone (916) 574-7900 Fax (916) 574-8618
ARNOLD SCHWARZENEGGER, GOVERNOR
www.pharmacy.ca.gov


INTERN PHARMACIST REGISTRATION INSTRUCTIONS

TO APPLY FOR REGISTRATION AS AN INTERN PHARMACIST IN CALIFORNIA, YOU MUST BE:

 Presently enrolled in a school of pharmacy recognized by the board or accredited by the
Accreditation Council for Pharmaceutical Education (ACPE),
OR  A graduate of a school of pharmacy recognized by the board or accredited by the Accreditation
Council for Pharmaceutical Education (ACPE) who also has an application pending to take the
California pharmacist licensure examinations,
OR  A graduate of a foreign pharmacy school who has obtained certification from the Foreign Pharmacy
Graduate Examination Committee (FPGEC). NOTE: You will not be issued an intern registration until
the board has received written verification from the FPGEC that you have obtained this certification.
[This process will take up to 12 weeks for the FPGEC to provide your results to the board.]
OR  A person who has failed the pharmacist licensure examination four times and has reenrolled in a school of
pharmacy to satisfy the requirements of Business and Professions Code section 4200.1.

SUBMITTING AN INTERN LICENSE APPLICATION


To be considered complete, an intern license application must include:

1. A completed Application for Registration as an Intern Pharmacist (Form 17A-17). All questions must be
answered and you must sign and date the form. A 2” x 2” passport type photo must be taped to the face of the
application. Photos taken by personal Polaroid cameras are unacceptable. If you are currently enrolled in a
school or college of pharmacy, the dean of that school must complete and sign the certification area on the
application, and emboss the application with the school’s seal.

2. A check or money order in the amount of $90, made payable to the “Board of Pharmacy.” Your cancelled check
is verification that your application has been received. If you would like notification from the board that your
application was received, please submit a postcard addressed to yourself with adequate postage affixed. The
board will mail this postcard when your application is received.

3. A copy of Request for Live Scan Service Form verifying that your fingerprints have been scanned and all
applicable fees have been paid. Refer to “Instructions for Completing Request for Live Scan Service Form” on the
board’s Web site (www.pharmacy.ca.gov). The board can only accept Requests for Live Scan Service Forms that
were processed in California. The board requires the applicant to have their fingerprints submitted at the time an
intern pharmacist application is submitted to the board regardless of any prior fingerprint submission for
pharmacist licensure examination or pharmacy technician applications with the board.

If you are unable to have your prints taken using Live Scan in California, you must submit rolled fingerprints (on
cards provided by the board) and a fee of $51made payable to “Board of Pharmacy.” (This fee covers: $32
California Department of Justice processing fee and $19 FBI processing fee.) Contact the board at (916) 574-
7900 to request fingerprint cards. Fingerprint cards are to be used ONLY when you cannot have your prints
taken in California using Live Scan. Fingerprints on cards must be taken by a person professionally trained in the
rolling of prints. Poor quality prints will result in the prints being rejected and will require that you be reprinted.
Reprinting may delay licensing.

Note to Applicants Submitting Fingerprints Via Live Scan: While the Live Scan forms contained in the
board’s application package are pre-slugged to indicate level of service at the DOJ and FBI level, please ensure
at the time of Live Scan transmission that the Live Scan operator selects both the DOJ and FBI levels of service.
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.

4. A copy of the FPGEC certificate if you are a graduate of a foreign school of pharmacy.

17M-42 (Rev. 1/10)

California State Board of Pharmacy STATE AND CONSUMERS AFFAIRS AGENCY
1625 N. Market Blvd, Suite N219, Sacramento, CA 95834
DEPARTMENT OF CONSUMER AFFAIRS
Phone (916) 574-7900
ARNOLD SCHWARZENEGGER, GOVERNOR
Fax (916) 574-8618
www.pharmacy.ca.gov

APPLICATION FOR REGISTRATION AS AN INTERN PHARMACIST

TO BE COMPLETED BY APPLICANT
Last
Name
First
Name

Middle

Former

*Address of Record:

Number
Street

Apartment No.

TAPE A PHOTOGRAPH TAKEN


City
State
Zip
Code
WITHIN 60 DAYS OF THE FILING

OF THIS APPLICATION
Residence Address: (if different from above) Number Street

Apartment No.

NO POLAROID



City State Zip Code

Home telephone number Work telephone number
Date of Birth
Social Security Number **
Email address





( )
( )
If you are a graduate from a foreign school of pharmacy provide:
Name of School:
Country:
Date Graduated:



*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 upon licensure. 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 mailbox (PMB). However, if your address of record is not your residence address, you must also provide your residence address as an
alternate address that will not be available to the public.

TO BE COMPLETED BY DEAN OF COLLEGE (If presently enrolled)
I,
being Dean of



(Name of Dean)

(Name of school or college)


a school or college of pharmacy recognized by the California State Board of Pharmacy, do hereby certify that:





(Name of Student)


whose application for intern pharmacist registration is shown on this form, is:



registered as a student in this institution seeking a degree in pharmacy.


Emboss School Seal Here

re-enrolled to satisfy the requirements of Business and Professions Code
section
4200.1

Year in school

Expected date of graduation










Signature
Title

Date

DO NOT WRITE BELOW THIS LINE
Livescan/FP Cards

FP Clear
Registration
no
App fee no.
Photo
Date issued
Amount
Rules
Enf
Date expires
Date cashiered

17A-17 (Rev. 10/07)
Page 1 of 3

1.
Are you a candidate for the licensure examination?
Yes No
2.
Have you previously applied for registration as an intern pharmacist with the board? If “yes”,
please provide date and intern registration number
Yes No
3.
Have you ever taken the California pharmacist licensure exam?
If “yes”, please provide date of exam
Yes No
4.
Have you ever applied and not taken the exam?
If “yes”, please provide exam date
Yes No
5.
Have you ever been expelled from a pharmacist licensure exam administered in this state or
any other state? If “yes”, please provide the date and state
Yes No

6.
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
Yes No
and safety risks? If “yes”, please attach a statement of explanation. If “no”, proceed to #7.

Are the limitations caused by your medical condition reduced or improved because you
receive ongoing treatment or participate in a monitoring program? If “yes”, please attach a
statement
of
explanation. Yes
No


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 so as to determine whether an unrestricted
license should be issued, whether conditions should be imposed, or whether you are not
eligible for licensure.
7.
Do you currently engage or have you been engaged in the past two years, in the illegal use of
controlled substances?
Yes No

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? If “yes”, please attach a statement of
explanation.
8.
Have you ever been convicted of or pled no contest to a violation of any law of the United
States, a foreign country or any state laws or local ordinances? You must include all
Yes No
misdemeanor and felony convictions, regardless of the age of the conviction, including those
which have been set aside under Penal Code section 1203.4 (Traffic violations of $500 or
less need not be reported).

If “yes”, please attach an explanation which must include the type of violation, the date,
circumstances, location, and the complete penalty received.
9.
Has disciplinary action ever been taken against your pharmacist or intern permit in this state
Yes No
or any other state? If “yes”, please attach a statement of explanation.

10. Have you ever had an application for a pharmacist license or an intern permit denied in this
state or any other state? If “yes”, please provide a statement of explanation.
Yes No
11. Have you had a pharmacy permit, or any professional or vocational license or registration
denied, suspended, revoked, or placed on probation or other disciplinary action taken by this
Yes No
or any other governmental authority in this state or any other state? If “yes”, please provide
the name of company, type of permit, type of action, year of action and state.
12. 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,
Yes No
wholesaler, medical device retailer or any other entity licensed in this state or any other
state? If “yes”, please provide company name, type of permit, permit number and state.

17A-17 (Rev. 10/07)
Page 2 of 3
You must provide a written explanation for all affirmative answers to questions 6 through 12. Failure to
do so will ultimately result in this application being deemed withdrawn as incomplete.

Please read carefully and sign below.

I understand that, as an intern pharmacist, I may not perform any duties required of a pharmacist except when I am working
under the direct and personal supervision of a pharmacist. I also understand that should I perform any duties for which I am
not licensed or should I take charge of and operate a pharmacy in the absence of a pharmacist, I am placing my ability to
become a licensed pharmacist in jeopardy.

I further understand that I must submit a record of my intern pharmacist experience on a form furnished by the Board,
certified by the pharmacist under whose immediate supervision such experience was attained in order to receive credit for
such experience toward completion of my experience requirement.

Applicant understands that falsification of the information on this form, may constitute grounds for denial or revocation of the
registration. I hereby certify under penalty of perjury under the laws of the State of California that all statements, answers
and representations made in the foregoing application, including all supplementary statements are true and correct. I also
certify that I personally completed this application. I understand that I must notify the board in writing of any change of
address during my internship. I have also read and understand the instructions attached to this application.



Signature of applicant (in full, no initials)

Date Signed

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. The information will be used to determine qualifications for registration under the California Pharmacy Law. The
official responsible for information maintenance is the executive officer, telephone (916) 574-7900, 1625 N. Market Blvd, Suite 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 1798.38 of the Civil Code.

** 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 and section 11350 of the Welfare and Institution 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 REPORTING

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.

17A-17 (Rev. 10/07)
Page 3 of 3
California State Board of Pharmacy STATE AND CONSUMERS AFFAIRS AGENCY
1625 N. Market Blvd, Suite N219, Sacramento, CA 95834
DEPARTMENT OF CONSUMER AFFAIRS
Phone (916) 574-7900
ARNOLD SCHWARZENEGGER, GOVERNOR
Fax (916) 574-8618
www.pharmacy.ca.gov

PHARMACY MANAGEMENT OBJECTIVE

(OPTIONAL)

The Board of Pharmacy, realizing the needs for an improved knowledge of pharmacy
management, would encourage interns to achieve the following objectives to develop
fundamental skills in economics, security, personnel development and patient relations.

1.
The Intern shall be able to discuss the underlying principles of preparation of a
budget, daily transactions and fiscal constraints necessary in the management of
the pharmacy.

2.
The Intern shall be able to accurately price a prescription, OTC medication and
other health related items and have an understanding of pricing policies.

3.
The Intern shall be able to efficiently order drug supplies both direct and wholesale
courses.

4.
The Intern shall be able to discuss and demonstrate methods of inventory control
and its relationship to good purchasing procedure.

5.
The Intern shall be able to discuss the various prepaid or third party plans and their
procedures and able to accurately complete and submit the appropriate forms for
reimbursement.

6.
The Intern shall be able to discuss the effective and appropriate utilization and
supervision of ancillary personnel.

7.
The Intern shall be capable of performing security procedures within the pharmacy.


1728. Requirements for Examination.

(a) Prior to receiving authorization from the board to take the pharmacist licensure
examinations required by section 4200 of the Business and Professions Code,
applicants shall submit to the board the following:

(1) Proof of 1500 hours of pharmacy practice experience that meets the following
requirements:

(A) A minimum of 900 hours of pharmacy practice experience obtained in
a pharmacy.



(B) A maximum of 600 hours of pharmacy practice experience may be
granted at the discretion of the board for other experience substantially
related to the practice of pharmacy.

(C) Experience in both community pharmacy and institutional pharmacy
practice settings.

(D) Pharmacy practice experience that satisfies the requirements for both
introductory and advanced pharmacy practice experiences established
by the Accreditation Council for Pharmacy Education.

(2) Satisfactory proof that the applicant graduated from a recognized school of
pharmacy.

(3) Fingerprints to obtain criminal history information from both the Department of
Justice and the United States Federal Bureau of Investigation pursuant to
Business and Professions Code section 144.

(4) A signed copy of the examination security acknowledgment.

(b) Applicants who hold or held a pharmacist license in another state shall provide a
current license verification from each state in which the applicant holds or held a
pharmacist license prior to being authorized by the board to take the examinations.

(c) Applicants who graduated from a foreign school of pharmacy shall provide the board
with satisfactory proof of certification by the Foreign Pharmacy Graduate Examination
Committee prior to being authorized by the board to take the examinations.


















17M-89 (Rev 5/06)

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; failure to do so may result in processing delays of your application.

NOTE TO APPLICANT and LIVE SCAN OPERATOR: The applicant’s name, date of birth and US Social
Security Number 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 any of the applicant’s name, date of birth or US Social Security
Number are not entered at the time of Live Scan transmission, the applicant may have to have a new Live
Scan transmission completed.

1. Job Title or Type of License, Certification, or Permit: Enter the type of license, certification or permit
for which you are applying. Appropriate license types include pharmacist, pharmacy technician, intern
pharmacist, exemptee, or if an owner or officer of a pharmacy, hospital, clinic, wholesaler or hypodermic
permit enter appropriate title of the facility.
2. Name of Applicant: Enter your last name, first name and middle name. Do not use initials or name
abbreviations.
3. AKA: Enter all other names you have used, including your maiden name.
4. CDL
No: Your California Driver’s License Number.
5. DOB: Your date of birth (month/day/year).
6. SEX: Your gender (male or female).
7. HT: Your height in feet and inches.
8. WT: Your weight in pounds.
9. Misc.
No.: Enter other identifying numbers. (e.g., Other State Driver’s License Number)
10. EYE
Color:
Color of your eyes
11. HAIR Color: Color of your hair
12. Home Address: Your residence address
13. POB: Enter your place of birth.
14. SOC: Enter your Social Security Number
15. Level of Service: While the Live Scan forms contained in the board’s application package are pre-
slugged to indicate level of service at the DOJ and FBI level, please ensure at the time of Live Scan
transmission that the Live Scan operator selects both the DOJ and FBI levels of service. 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.

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 http://ag.ca.gov/fingerprints/publications/contact.htm 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.

17M-15 (11/08)
Page 1 of 1


REQUEST FOR LIVE SCAN SERVICE
Applicant Submission
A0071

ORI: Type of Application: (check one)
Employment License, Certification, Permit
Volunteer
Code assigned by DOJ
Job Title or Type of License, Certification or Permit: Pharmacy Intern - Section 4015
(See instruction sheet for appropriate license types)
Agency Address Set Contributing Agency:
Board of Pharmacy
05712
Agency authorized to receive criminal history information
Mail Code (five-digit code assigned by DOJ)
1625 N. Market Blvd, Suite N219
Street No.
Street or PO Box
Contact Name (Mandatory for all school submissions)
Sacramento, CA 95834
( )
916
574-7900
City
State
Zip Code
Contact Telephone No.
Name of Applicant:
(Please print) Last First Middle
AKA’s:
CDL No.
Last
First
California Driver's License Number
DOB:
SEX:
Male
Female
Misc. No.
Applicant to pay fees
BIL -
Date of Birth
Agency Billing Number (if applicable)
HT:
WT:
Misc. No.
Height
Weight
Other State Driver's License Number
EYE Color: HAIR Color: Home Address:
POB:
Street or PO Box
Place of Birth
SOC:
City, State and Zip Code
Social Security Number
Your Number: XXXXXXXXXXXXXXXX
OCA No. (Agency Identifying No.)
Level of Service DOJ FBI
If resubmission, list Original ATI No.

Employer: (Additional response for Department of Social Services, DMV/CHP licensing, and Department of Corporations submissions only)
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Employer Name
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXX
Street No.
Street or PO Box
Mail Code (five digit code assigned by DOJ)
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXX
( )
City
State
Zip Code
Agency Telephone No. (Optional)
Live Scan Transaction Completed By:
Date
Name of Operator
Transmitting Agency
ATI No.
Amount Collected/Billed
BCII 016 (rV 10/98) ORIGINAL-Live Scan Operator; SECOND COPY-Board of Pharmacy; THIRD COPY-Applicant
ORIGINAL
REQUEST FOR LIVE SCAN SERVICE
Applicant Submission
A0071

ORI: Type of Application: (check one)
Employment License, Certification, Permit
Volunteer
Code assigned by DOJ
Job Title or Type of License, Certification or Permit: Pharmacy Intern - Section 4015
(See instruction sheet for appropriate license types)
Agency Address Set Contributing Agency:
Board of Pharmacy
05712
Agency authorized to receive criminal history information
Mail Code (five-digit code assigned by DOJ)
1625 N. Market Blvd, Suite N219
Street No.
Street or PO Box
Contact Name (Mandatory for all school submissions)
Sacramento, CA 95834
( )
916
574-7900
City
State
Zip Code
Contact Telephone No.
Name of Applicant:
(Please print) Last First Middle
AKA’s:
CDL No.
Last
First
California Driver's License Number
DOB:
SEX:
Male
Female
Misc. No.
Applicant to pay fees
BIL -
Date of Birth
Agency Billing Number (if applicable)
HT:
WT:
Misc. No.
Height
Weight
Other State Driver's License Number
EYE Color: HAIR Color: Home Address:
POB:
Street or PO Box
Place of Birth
SOC:
City, State and Zip Code
Social Security Number
Your Number: XXXXXXXXXXXXXXXX
OCA No. (Agency Identifying No.)
Level of Service DOJ
FBI
If resubmission, list Original ATI No.

Employer: (Additional response for Department of Social Services, DMV/CHP licensing, and Department of Corporations submissions only)
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Employer Name
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXX
Street No.
Street or PO Box
Mail Code (five digit code assigned by DOJ)
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXX
( )
City
State
Zip Code
Agency Telephone No. (Optional)
Live Scan Transaction Completed By:
Date
Name of Operator
Transmitting Agency
ATI No.
Amount Collected/Billed
BCII 016 (Rev 10/98) ORIGINAL-Live Scan Operator; SECOND COPY - Board of Pharmacy; THIRD COPY-Applicant
SECOND COPY
REQUEST FOR LIVE SCAN SERVICE
Applicant Submission
A0071

ORI: Type of Application: (check one)
Employment License, Certification, Permit
Volunteer
Code assigned by DOJ
Job Title or Type of License, Certification or Permit: Pharmacy Intern - Section 4015
(See instruction sheet for appropriate license types)
Agency Address Set Contributing Agency:
Board of Pharmacy
05712
Agency authorized to receive criminal history information
Mail Code (five-digit code assigned by DOJ)
1625 N. Market Blvd, Suite N219
Street No.
Street or PO Box
Contact Name (Mandatory for all school submissions)
Sacramento, CA 95834
( )
916
574-7900
City
State
Zip Code
Contact Telephone No.
Name of Applicant:
(Please print) Last First Middle
AKA’s:
CDL No.
Last
First
California Driver's License Number
DOB:
SEX:
Male
Female
Misc. No.
Applicant to pay fees
BIL -
Date of Birth
Agency Billing Number (if applicable)
HT:
WT:
Misc. No.
Height
Weight
Other State Driver's License Number
EYE Color: HAIR Color: Home Address:
POB:
Street or PO Box
Place of Birth
SOC:
City, State and Zip Code
Social Security Number
Your Number: XXXXXXXXXXXXXXXX
OCA No. (Agency Identifying No.)
Level of Service DOJ FBI
If resubmission, list Original ATI No.

Employer: (Additional response for Department of Social Services, DMV/CHP licensing, and Department of Corporations submissions only)
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Employer Name
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXX
Street No.
Street or PO Box
Mail Code (five digit code assigned by DOJ)
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXX
( )
City
State
Zip Code
Agency Telephone No. (Optional)
Live Scan Transaction Completed By:
Date
Name of Operator
Transmitting Agency
ATI No.
Amount Collected/Billed
BCII 016 (Rev 10/98) ORIGINAL-Live Scan Operator; SECOND COPY - Board of Pharmacy; THIRD COPY - Applicant
THIRD COPY

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