Individual Personal Affidavit {17A-27}

17A-27 - INDIVIDUAL PERSONAL AFFIDAVIT. This form is to be completed by each individual listed on a facility application or license. A California licensed pharmacist and any designated representative license ONLY acting as a pharmacist-in-charge/consulting pharmacist/designated representative-in-charge/responsible manager is not required to complete this form, unless listed as an owner, officer, director, manager, member, partner, stockholder, trustee, professional director, or the administrator (government owned) on the application. www.FormsWorkflow.com