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Reinstatement Reactivation Application, Summaries of Pharmacy

University of California - Los Angeles (UCLA)Pharmacy

APPLICATION FOR REINSTATEMENT/REACTIVATION OF GEORGIA PHARMACY LICENSE. APPLICATIONS VALID FOR ONE (1) YEAR. Please submit your application in a 9 X 12 or ...

Typology: Summaries

2022/2023

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bg1
Georgia Board of Pharmacy
2 Peachtree Street, N.W., 6th Floor
Atlanta, GA 30303
(404) 651-8000 www.gbp.georgia.gov
APPLICATION FOR REINSTATEMENT/REACTIVATION OF GEORGIA PHARMACY LICENSE
APPLICATIONS VALID FOR ONE (1) YEAR
Please submit your
application
in a 9 X 12 or larger envelope with pages
unstapled
and
unfolded.
The
Reinstatement
Fee is
non-refundable
The fee for checks returned due to
non-sufficient
funds is
$40.00.
FEES:
Reinstatement - $300.00 renewal fee for each renewal period not renewed and $350.00 reinstatement
fee
Reactivation - $200.00 for each renewal period not
renewed
PLEASE CHECK ONE: I am applying for ( ) Reinstatement ( ) Reactivation
1. Name:
(Last) (First) (Middle)
2. Home Address:
(City) (State) (Zip)
3. Phone Number: ( ) - W ork Number: -
4. Email Address
Acknowledgement
of your
application
will be sent by email. Also, if further
information
is needed, email is the most
efficient way for Board staff to contact you so that your
application
can be
processed
in the most
efficient
manner.
Your email address will not be shared with any third party.
5. Date of Birth: / / Social Security #: - -
6. Georgia Pharmacy License Number:
7. If you are now, or have ever been licensed to practice pharmacy in another state, you are required to
have your license verified by that State Board of Pharmacy, sealed in an envelope, and sent with this
application.)
8. On a separate sheet submit a C.V. indicating past work histories, going back to date of expiration.
9. Since the date of expiration, have you been practicing pharmacy?
( )Yes ( )No
If you have practiced since your license lapsed, what were your dates of practice ?
At what pharmacy was said practice?_
1
Do Not Write in this Section:
Receipt#:
Amount:
Applicant#:
Initials/Date:
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pf5
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pf9

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Georgia Board of Pharmacy

2 Peachtree Street, N.W., 6th Floor

Atlanta, GA 30303

(404) 651- 8000 www.gbp.georgia.gov

APPLICATION FOR REINSTATEMENT/REACTIVATION OF GEORGIA PHARMACY LICENSE

APPLICATIONS VALID FOR ONE ( 1 ) YEAR

Please submit your application in a 9 X 12 or larger envelope with pages unstapled and unfolded. The Reinstatement Fee is non-refundable The fee for checks returned due to non-sufficient funds is $ 4 0.0 0. FEES: Reinstatement - $300.00 renewal fee for each renewal period not renewed and $350.00 reinstatement fee Reactivation - $200.00 for each renewal period not renewed PLEASE CHECK ONE: I am applying for ( ) Reinstatement ( ) Reactivation

  1. Name: (Last) (First) (Middle)
  2. Home Address: (City) (State) (Zip)
  3. Phone Number: ( ) - W ork Number: -
  4. Email Address Acknowledgement of your application will be sent by email. Also, if further information is needed, email is the most efficient way for Board staff to contact you so that your application can be processed in the most efficient manner. Your email address will not be shared with any third party.
  5. Date of Birth: (^) / / Social Security #: - -
  6. Georgia Pharmacy License Number:
  7. If you are now, or have ever been licensed to practice pharmacy in another state, you are required to have your license verified by that State Board of Pharmacy, sealed in an envelope, and sent with this application.)
  8. On a separate sheet submit a C.V. indicating past work histories, going back to date of expiration.
  9. Since the date of expiration, have you been practicing pharmacy? ( )Yes ( )No If you have practiced since your license lapsed, what were your dates of practice? At what pharmacy was said practice?_ Do Not Write in this Section: Receipt#: Amount: Applicant#: Initials/Date:

  1. Have you kept your Continuing Pharmaceutical Education hours current? ( ) Yes ( ) No (Attach COPIES of your most recently obtained 3 0 hours)

  2. Have you ever been convicted of a misdemeanor or felony? ( )Yes ( )No (If yes, you must attach a copy of the court disposition sheet(s) and an explanation of the charge(s).

  3. If you hold or did hold a license in another state, please answer the following question: Have you ever had your license revoked or suspended, or otherwise sanctioned by any board or agency in another state? ( )Yes ( )No ( )N/A (If yes, you must attach a copy of the order and an explanation).

  4. To your knowledge, are you the subject of an investigation by any licensing board or agency as of the date of this application? ( )Yes ( )No ( )N/A (If yes, attach an explanation.)

  5. W ithin the previous two (2) years, have you been dependent on alcohol or any other drug, or been treated for dependency on alcohol or any other drug? ( )Yes ( )No (If yes, attach explanation.)

  6. Do you have any physical or mental condition(s) which renders you unable to practice pharmacy with reasonable skill and safety to patients? ( )Yes ( )No (If yes, attach explanation.) I acknowledge and state that I have read the application instructions on the first page of this application and I have answered all questions in compliance with these instructions. I acknowledge that it is my responsibility to read and become familiar with the Georgia State Board of Pharmacy Rules, Laws, and Practice Act. I further acknowledge that if I have been out of practice for four ( 4 ) or more years, that I must comply with Board Policy # 3 (A), and that if my license was Administratively Revoked for failure to renew, I will have to comply with Board Policy #3(B) and/or Policy #4 and that I have read and understand the attached copies of these policies. By signing this application, I certify that the foregoing information is true and correct to the best of my knowledge. (Signature of Applicant) (Date) Sworn to and subscribed before me this the day of _, 20. (Signature of Notary Public) My Commission Expires: (Notary Seal)

CONSENT FORM

I hereby authorize the GEORGIA STATE BOARD OF PH ARM ACY to receive any criminal history

record information pertaining to me which may be in the files of any state or local criminal justice

agency in Georgia. I also give consent to the Georgia State Board of Pharmacy to perform

periodic criminal background checks for the duration of my active licensure status with this state.

(Applicant’s Full Name – Printed)

Physical Address (P.O. Boxes NOT Accepted)

Sex Race Date of Birth Social Security Number

Place of Birth (City/State):

Aliases or Maiden Name:

(Signature of Applicant) (Date)

STATE LICENSURE CERTIFICATION

TO THE APPLICANT: Please complete the top section of this form and mail to each state in which you

are now or have been licensed to practice pharmacy. This form may be reproduced as necessary.

TO: Board of Pharmacy

I am applying for licensure and the Georgia Board requires that your Board complete this form in order that

my application for licensure/reinstatement may be considered. By signing this form, I am giving my consent

to the release of any information, favorable or otherwise, for its review in considering me for licensure.

My license Number was issued by your Board on on the basis of ( ) State

Board Exam, ( ) Reciprocity/Endorsement, ( ) National Board, ( ) Credentials, ( ) other.

Applicant's Full Name (print or type) Address

Signature City State Zip

This section to be completed by an official of the above referenced licensing board.

Please return this form directly to the applicant in a sealed envelope.

Pharmacist License number to practice pharmacy in the State of

was issued on

Is license current and in good standing? ( ) Yes ( ) No*

to.

Licensee

Has any disciplinary action ever been taken against this license? ( ) Yes* ( ) No

*Please provide complete details, including copies of any documents.

Signature Date

Title (B0ARD SEAL)

Licensing Board

Policy #3B Guidelines for Reinstatement/Reactivation of Pharmacists’ Licenses who HAVE been actively practicing pharmacy during the past four (4) years. (This could pertain to a pharmacist whose license is on “Inactive” status, or a pharmacist whose license was administratively lapsed due to non-renewal, voluntarily surrendered or suspended for disciplinary reasons.)

  1. Applicants must submit a written request to the Board’s office for reinstatement/reactivation.
  2. Pay all back renewal and/or penalty fees.
  3. Complete and submit proof of 30 hours of Pharmaceutical Continuing Education obtained during the past two (2) years.
  4. Submit a Curriculum Vitae (C.V.) indicating past work activities, going back to date of expiration.
  5. If licensed in another state, have verification of license forwarded to the Georgia State Board of Pharmacy’s office. If the license was administratively lapsed due to non-renewal the board, in its discretion may also require one or all of the following:
  6. Inclusion in the CE audit pool for the upcoming renewal cycle.
  7. Board may request to meet with licensee prior to license being reinstated.

APPLICANT: PLEASE CHECK THE FORM OF IDENTIFICATION BELOW THAT YOU

POSSESS. RETURN THIS FORM ALONG WITH A COPY OF YOUR APPROPRIATE

DOCUMENTATION.

Name

Secure and Verifiable Documents Under O.C.G.A. § 5 0 - 36 - 2

Issued August 1, 2011 by the Office of the Attorney General, Georgia

The Illegal Immigration Reform and Enforcement Act of 2011 (“IIREA”) provides that “[n]ot later than

August 1, 2011, the Attorney General shall provide and make public on the Department of Law’s website a

list of acceptable secure and verifiable documents. The list shall be reviewed and updated annually by the

Attorney General.” O.C.G.A. § 50 - 36 - 2 (f). The Attorney General may modify this list on a more frequent

basis, if necessary.

The following list of secure and verifiable documents, published under the authority of O.C.G.A. § 50 - 36 - 2,

contains documents that are verifiable for identification purposes, and documents on this list may not

necessarily be indicative of residency or immigration status.

A United States passport or passport card [O.C.G.A. § 5 0 - 36 - 2 (b)(3); 8 CFR § 2 74 a.2]

A United States military identification card [O.C.G.A. § 5 0 - 36 - 2 (b)( 3 ); 8 CFR § 2 74 a.2]

A driver’s license issued by one of the United States, the District of Columbia, the

Commonwealth of Puerto Rico, Guam, the Commonwealth of the Northern Marianas Islands, the

United States Virgin Island, American Samoa, or the Swain Islands, provided that it contains a

photograph of the bearer or lists sufficient identifying information regarding the bearer, such as

name, date of birth, gender, height, eye color, and address to enable the identification of the bearer

[O.C.G.A. § 50- 36 - 2 (b)( 3 ); 8 CFR § 274a.2]

An identification card issued by one of the United States, the District of Columbia, the

Commonwealth of Puerto Rico, Guam, the Commonwealth of the Northern Marianas Islands, the

United States Virgin Island, American Samoa, or the Swain Islands, provided that it contains a

photograph of the bearer or lists sufficient identifying information regarding the bearer, such as

name, date of birth, gender, height, eye color, and address to enable the identification of the bearer

[O.C.G.A. § 50- 36 - 2 (b)( 3 ); 8 CFR § 274a.2]

A tribal identification card of a federally recognized Native American tribe, provided that it contains a

photograph of the bearer or lists sufficient identifying information regarding the bearer, such as name,

date of birth, gender, height, eye color, and address to enable the identification of the bearer. A listing

of federally recognized Native American tribes may be found at:

http://www.bia.gov/WhoWeAre/BIA/OIS/TribalGovernmentServices/TribalDirectory/index.htm

[O.C.G.A. § 50- 36 - 2 (b)( 3 ); 8 CFR § 274a.2]

A United States Permanent Resident Card or Alien Registration Receipt Card [O.C.G.A. § 50 - 36 -

2 (b)( 3 ); 8 CFR § 274a.2]

An Employment Authorization Document that contains a photograph of the bearer [O.C.G.A. § 50-

36 - 2 (b)(3); 8 CFR § 27 4 a.2]