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 01012016CONSENTED 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