Form 36028 - Application For Pharmacist'S License Page 2
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3If your answer is "Yes" to any of the following, explain fully in a sworn affidavit, including all related detail. Describe the event including the
location, date and disposition. If you have had a malpractice judgment , provide the name of the plaintiff. Falsification of any of the following
is grounds for permanent revocation of a license or permit issued pursuant to the application.
Except for minor violations of traffic laws resulting in fines
AUTHORIZATION FOR RELEASE OF INFORMATION
AFFIRMATION
month, day, year
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Parent category: Business