District Of Columbia > Statewide > Health And Licensing Administration > Pharmaceutical Control
Controlled Substance Registration Application - District Of Columbia
| Controlled Substance Registration Application Form. This is a District Of Columbia form and can be used in Pharmaceutical Control Health And Licensing Administration Statewide . |
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GOVERNMENT OF THE DISTRICT OF COLUMBIA Department of Health Health Regulations and Licensing Administration Pharmaceutical Control 899 North Capitol Street, NE Washington DC 20002 FOR OFFICIAL USE ONLY! Application Complete: YES Approved Registration: YES FOR OFFICIAL USE ONLY! DATE: REG NO: INITIALS: Controlled Substances Registration Application Incomplete or illegible application packages will not be processed. Please refer to registration application instructions. PLEASE PRINT LEGIBLY OR TYPE ALL ENTRIES Initial Application LAST NAME FIRST NAME Renewal Application Registration Number To have registration mailed to another address other than the business address, please provide mailing address D.C. BUSINESS OR HOSPITAL AFFILIATION NAME LAST NAME FIRST NAME D.C. BUSINESS OR HOSPITAL AFFILIATION ADDRESS (DO NOT USE PO BOX) MAILING ADDRESS ZIP CITY STATE CITY STATE ZIP PHONE NUMBER FAX NUMBER 3. CONTROLLED SUBSTANCE SCHEDULES: Check all applicable controlled substances schedules in which you intend to handle. Schedule I Schedule III (Non-Narcotic) Schedule II Schedule IV Schedule III (Narcotic) Schedule V EMAIL ADDRESS 1. BUSINESS ACTIVITY: Manufacturer Analytical Lab Maintenance and/or Detoxification Distributor CHECK ONLY ONE Pharmacy Researcher Other: Hospital/Clinic Practitioner Specify Health Degree: Importer/Exporter Teaching Institution 4. CERTIFICATION FOR FEE EXEMPTION CHECK IF INDIVIDUAL NAMED HEREON IS A D.C. OFFICIAL The undersigned hereby certifies that the applicant hereon is an officer or employee of a local D.C. agency who, in the course of such employment, is authorized to obtain, dispense, prescribe, or otherwise handle controlled substances. Signature of Certifying Official Date 2. ALL APPLICANTS MUST ANSWER THE FOLLOWING: (a) Is the applicant currently authorized to prescribe, manufacture, distribute, conduct research or instructional activities or chemical analysis with or otherwise handle the controlled substances in the schedules for which you are applying for, under the laws of District of Columbia? Yes D.C. License Number: Not Applicable (b) Has the applicant ever been convicted of a felony in connection with controlled substances (CS) under D.C., State or Federal law, or ever surrendered or had a CS registration revoked, or suspended or denied? YES NO (c) If the applicant is a corporation, association or partnership, has any officer, partner, stockholder or proprietor been convicted of a felony in connection with CS under D.C., State or Federal law, or ever surrendered or had a CS registration revoked, or suspended or deni YES NO IF THE ANSWER TO QUESTIONS (b) AND/OR (c) IS YES, INCLUDE A SIGNED STATEMENT EXPLAINING SUCH RESPONSES. MAIL THIS APPLICATION TO ABOVE ADDRESS Print Certifying Name and Title Name of Governmental Institution and Agency 5. I CERTIFY THAT ALL OF THE STATEMENTS MADE ARE TRUE, COMPLETE, AND CORRECT TO THE BEST OF MY KNOWLEDGE. Signature of Applicant or Authorized Individual Print Name and Title Date American LegalNet, Inc. www.FormsWorkFlow.com
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