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BEFORE THE GEORGIA STATE BOARD OF PHARMACY STATE OF GEORGIA IN THE MATTER OF: * 5 : Acne NetnanPeice eh. Gino fart License No. RPH_)20534 * NOV 13 2017 Respondent VoL Y SI TNA CO ep oer of react ates RPHQOS3 bo practice pharmacy in the State of Georgia pursuant to 0.C.G.A. Ch. 26-4, as amended, hereby freely, knowingly and voluntarily surrender said license to the Georgia State Board of Pharmacy. Thereby acknowledge that this surrender shall have the same effect as a revocation of my license, and I knowingly forfeit and relinquish all righ, title and privilege of practicing pharmacy in the State of Georgia, unless and until such time as my license may be reinstated, in the sole discretion of the Board. Lunderstand that I will be expected, in making any application or request for restoration of my license, to show my fitness to resume the practice of pharmacy. I understand that Ihave a right to a hearing in this matter, and I hereby freely, knowingly and voluntarily waive suek right. 1 also understand that should any request for reinstatement be entertained by the Board, the Board shall have access to the entire investigative file in this matter. This surrender shall become effective immediately upon acceptance thereof by the Georgia State Board of Pharmacy. Iunderstand that this document will be considered to be a public record evidencing disciplinary action taken against my license by the Georgia State Board of Pharmacy with my consent. Version 01012016 CONSENTED TO: Respondent ayy, Sworn to and Subseribed SOR Ha, before me this_ 20th day of _Obbe _, 2ol7. “okt “inp COUN NOTARY PUBLIC mini (Notary Seal Required) My Commission expires: 2///5/2 | ACC. ICE OF SI R The voluntary surrender of License RPH 620S3@ is hereby accepted by the Georgia State Board of Pharmacy, this _@** dayot_Nevember gol, GEORGIA STATE BOARD OF PHARMACY President (Board Seal) ATTEST: Dogs Acti ‘anja Battle Executive Director @) Version 01012016

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