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. 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. We do not change anything on import. Corrections and reprints are $50.

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. 

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, or mixed, as appropriate on this form. The way it is entered is the way it will appear on your documentation for the State.

Here are some common errors that have caused delay in getting your documentation.

• Name is spelled incorrectly.

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

• 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.

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.

Course Completion Information

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 may result in the revocation of my license. 

5. Further reprints due to student entry errors above result in a $36 reprint charge.