Get Form 17a

Filling out Form 17a online is a straightforward process that ensures your personal background information is accurately submitted to the California State Board of Pharmacy. This guide provides you with step-by-step instructions to assist you in completing the form effectively.

Follow the steps to complete Form 17a online with ease.

1. Click the ‘Get Form’ button to obtain the form and open it in your browser.
2. Begin by entering your full name, including your last name, first name, and middle name in the designated fields.
3. Fill out your telephone number, ensuring you include the area code.
4. Complete your address by providing the number and street, city, state, and zip code.
5. Enter your date of birth in the format MM/DD/YY.
6. Input your Social Security number; note that this is mandatory for processing your application.
7. Indicate your status by selecting appropriate boxes for sole owner or other options.
8. If applicable, provide any previous names, including maiden names and any aliases.
9. State the name of the applicant’s business as well as the applicant’s address.
10. Address the question regarding previous management roles in partnerships or corporations related to denied, revoked, or suspended licenses.
11. If you have had a professional license action taken against you, fill in the necessary information for each relevant action.
12. Respond to queries regarding violations of California pharmacy law by detailing the type and action taken.
13. Disclose any convictions or no-contest pleas, making sure to list all misdemeanors and felonies, as instructed.
14. Complete the questions regarding illegal use of controlled substances and any participation in rehabilitation programs.
15. Review your entries for accuracy before signing and dating the form at the bottom.
16. Finally, save your changes, download, print, or share the form as needed.

Start completing your documents online today.