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Congratulations!
By SkillsPlus International

You have successfully completed of the Designated Representative Certification class for the California Board of Pharmacy or the Exemptee Certification class for DHS as an Exemptee for a Home Medical Device Retailer.

Please confirm that the forms listed below are the most current form before you use them. It should have the current Governor's name in the upper right corner of the form. We provide this as a courtesy only and cannot assume liability should the state move or fail to update this link.

Board of Pharmacy Designated Representative Application Form

DHS Home Medical Device Retailer Application Form

 

All you need to do now is to complete the form below below and we will  generate the documentation that you need to send to the California Board of Pharmacy and/or Department of Health for HMDR as you indicate below. In the cover letter that you receive you will receive detailed instructions on your next steps.

 

About Completing This Form

 

Please read the information below before completing and submitting this form. It may save you several days of delay in receiving the correct documentation and it will save you money.

 

Payment If you have not paid for this class, please contact our office before completing this form. Submission of this form prior to payment will delay your documentation by at least one week.

 

Appearance of Information Please use upper and lower case as appropriate on this form. The way it is entered is the way it will appear on your documentation for the State.

 

Make all entries as you want them to appear on your documents. The data from this form is automatically imported into a certificate processor and the data cannot be verified for you.

 

Corrections and reprints are $50.

 

Here are some common errors that have caused students to request the $50 reprint or have caused extreme delay in getting your documentation.

  • Name is spelled incorrectly.

  • The date you started the class AND the date you completed the class were missing.

  • Your home address is incorrectly stated.

  • Your company address is incorrect and FedEx cannot deliver the documents.

  • The only acceptable blank field below is the maiden name. If you do not have a middle name use "No Middle Name" or leave it blank.

  • When asked for your work address it is for FedEx delivery. PO Boxes are not acceptable. If your work addressed is not staffed, please call our office before submitting this form.

Why We Have A Reprint Fee: Lately we have had many students incorrectly enter data, requiring us to reprint and re-ship the forms. As a result we need to institute a procedure for requesting reprints. If the information entered is not correct and we have to reprint the documents we must charge a $50 fee. We appreciate your understanding. 

 

Personal Information 

This is about the person for whom the certificate will be generated. This is needed for the paperwork you will send to the California Board of Pharmacy. Once you type your first name use the TAB key to advance automatically to the next space.

Form Information Needed Form Field Special Instructions
First Name For our students with international backgrounds this is the first name that you use on US Government documents such as passport or green card.
Middle Name This is optional.
Maiden name  This can be left blank. A maiden name is a woman's name prior to marriage and taking the last name of the spouse.
Last Name or Surname For our students with international backgrounds this is the last name that you use on US Government documents such as passport or green card. If your last name is hyphenated, please entered it that way here also.
Home Street Address If you use your work address your license may be delayed by the Board of Pharmacy. The State uses the home address to mail your renewal certificates. Should you change your place of employment your renewal may not get to you in time. There is a late renewal penalty.
Home City
Home State Please use the two CAPITAL letter abbreviation. It looks best on your form.
Home Zip Code  
Home Telephone This format looks the best on your documentation xxx-xxx-xxxx
Email Address This is used to notify of the delivery status of your documentation AND we use it to inform you of course updates and new course that may be useful to your business. If you do not want to receive this information please leave this blank.

Employer Information

This is needed primarily for sending the training paperwork to you. Registration includes next day delivery, if it is available in your area. Please be sure the address you provide has someone there to receive the documents. 

 

Company Name  
Company Physical Address PO Boxes are not acceptable for most overnight delivery services we use.
Company City
Company State Please use the two CAPITAL letter abbreviation. It looks best on your form.
Company Zip Code  
Work Telephone Number This is used by the State if they need to call you AND if FedEx cannot locate your business from the address provided.
Course Start Date Please do not leave this field blank. Why can't we input this automatically? Because some people are not in a hurry and they may have started their class last year.
Course Completion Date
Special Delivery Instructions
Please do not use the enter button in this field. Your data will be corrupted.		 We will automatically ship to your business address. Use this field to tell us to ship to a different address such as a corporate office or to the attention of your supervisor. Please do not use the enter button in this field. Your data will be corrupted.

 

Certification Statement: I certify under penalty of perjury that the following five statements are true and understood.

  1. That I have personally checked all entries above and they are correct. 

  2. Further, I have taken the exam and it reflects my sole work and knowledge. 

  3. Additionally, that the above information is true and correct to the best of my knowledge. 

  4. I understand that obtaining a certificate through fraud will result in the revocation of my license. 

  5. Further reprints due to student entry error results in a $50 reprint charge.

 

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