SSPPS Appointment Request Form

First Name:

Middle Name or Initial: (Please do not leave this field blank. If no middle name or initial write “N/A”)

Last Name:

Email:

Date of Birth (YYYY/MM/DD):

Current Employer:

Provide your California Pharmacy License Number

Provide a brief description of your role/responsibility related to this request:

Have you ever had a UC San Diego Login user name?