APPLICATION FOR APPOINTMENT TO THE PHARMACY AND THERAPEUTICS COMMITTEE 2025

1. Click ‘Get Form’ to open the APPLICATION FOR APPOINTMENT TO THE PHARMACY AND THERAPEUTICS COMMITTEE in our editor.
2. Begin with SECTION 1: IDENTIFICATION AND CONTACT INFORMATION. Fill in your last name, first name, middle initial, and any suffix. Provide your mailing address, email address, phone number, fax number, National Provider Identifier, California Professional License Number, and its expiration date.
3. Move to SECTION 2: EDUCATION. Enter the name of your medical or pharmacy school, degree obtained, date of degree, and location details.
4. In SECTION 3: QUALIFYING KNOWLEDGE OR EXPERTISE, indicate your expertise by checking 'Yes' or 'No' for each area listed. Provide explanations for your experience as needed.
5. For SECTION 4: CURRENT PROFESSIONAL STATUS, confirm if you are actively engaged in treating injured workers by selecting 'Yes' or 'No'.
6. Complete SECTION 5 by attaching your Curriculum Vitae and any other relevant documents as specified.
7. In SECTION 6: AFFIRMATIONS, initial each box to affirm your agreement with the statements provided.
8. Finally, in SECTION 7: VERIFICATION, review all information for accuracy before signing and dating the application.

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