Initial Application For Registration For Dispenser - Pharmacy (Controlled Dangerous Substance)

Division of Consumer Affairs Drug Control Unit 124 Halsey Street, 3rd Floor, P.O. Box 45045, Newark, NJ 07101 (973) 504-6351 Controlled Dangerous Substance Registration Instruction sheet Enclosed is a Controlled Dangerous Substance (C.D.S.) application, which you are required to submit pursuant to N.J.S.A. 24:21-1 et seq q analysis utilizing controlled dangerous substances. A New Jersey C.D.S. registration is issued only for a New Jersey location. Be sure to include a $20.00 check or money order, y payable to "State of New Jersey." It will take 4-6 weeks to process this application. Your C.D.S. registration will be mailed to p pp Please note: 1. If you have a current D.E.A. number in another state and plan to discontinue practice in that state, you may transfer that D.E.A. number to New Jersey by providing the following to the Drug Enforcement Administration, 80 Mulberry Street, Newark, New Jersey 07102, (888-356-1071) www.deadiversion.usdoj.gov: jg d. a letter requesting an address change to the same address that is on your New Jersey C.D.S. registration. 2. If you plan to practice in both New Jersey and the state(s) where you currently hold a D.E.A. registration(s), you must also obtain a D.E.A. registration for New Jersey. Please contact the D.E.A. at the address indicated above and complete the New Jersey application. In order to complete the attached application, please note: a. A dispenser/prescriber/ practitioner includes medical doctors, doctors of osteopathy, dentists, optometrists, veterinarians, and nurse midwives. Pharmacies must complete a separate application. c. d. e. f. g. · · registration for that purpose. Federal facilities do not require registration. The address supplied must be current and an actual location where controlled dangerous substances will be stored, prescribed, dispensed, etc. Dentists and optometrists may only register at the address for which they hold a current registration issued by their board and at which the C.D.S. registration is required pursuant to 3(c) above. Individual practitioner applicants (medical doctors, dentists, veterinarians, etc.) must use their own name, not professional association/corporation or partnership information. Pharmacies are required to use their common trading name (e.g. David Pharmacy), not a business or corporate name. Dispensers/Prescribers must have an active and current New Jersey professional license number. Please write in your New Jersey professional license number in "Section B" of the application. Advanced Practice Nurses may prescribe controlled dangerous substances, but may not purchase or maintain any stock supplies of any C.D.S. medication. Optometrists are authorized to prescribe/dispense only Schedule III, IV and V controlled substances and must have an O.M. number registered with their board. 3. 4. If more space is required for your response to any question on the application, please submit a separate sheet of paper identifying the section(s) to which you are responding. If we can be of further assistance, please call 973-504-6351. New Jersey Is An Equal Opportunity Employer Printed on Recycled Paper and Recyclable American LegalNet, Inc. www.FormsWorkFlow.com 6/08 Drug Control Unit P.O. Box 45045 Newark, NJ 07101 Initial Application for Registration for Dispenser ­ Pharmacy New Jersey Controlled Dangerous Substances Act N.J.S.A. 24:21-1 et seq. Section B: Pharmacy Licensure Information Pharmacy permit number _____________________________________ Section C: Business Information 1. List the name, address and telephone number of the person who has administrative or managerial responsibility for the registered location. Section A: All of the items in this section must be completed. 1. Provide the applicant's name and the place of business to be registered (do not use solely a P.O. box). Registration will be provided for New Jersey locations only. If the registration is for a University of Medicine and Dentistry of New Jersey facility, include the department, room number, designation, e.g. MEB, MSB, etc. The address of record must be your practice location. ________________________________________________________ Pharmacy trade name ________________________________________________________ Last name First name C.D.S. ­ Responsible Individual MI ________________________________________________________ Department Room number ________________________________________________________ Street address 2. List the name, address and telephone number of the registered agent (if a corporation) or the name and address of the New Jersey resident upon whom process may be served (if a nonresident proprietor or partner). ________________________ City New Jersey __________________ ZIP code ____________________________ Home telephone number (include area code) __________________________ Business telephone number (include area code) Note: Please note that the above-registered address is subject to inspection pursuant to N.J.S.A. 24:21-31 & 32. 2. Registration requested as: Dispenser ($20) Section D: Make the check or money order payable to: State of New Jersey 3. Registration requested in the following Schedule(s): II III IV V Schedule 4. (a) Has any restriction been imposed which would affect your privilege to hold a controlled dangerous substances (C.D.S.) registration for Schedule II, III, IV or V substances in New Jersey, any other state, the District of Columbia or in any other jurisdiction?* Yes No (b) Have you been arrested, indicted or convicted of a crime in connection with controlled substances under federal law or the laws of New Jersey, any other state, the District of Columbia or any other jurisdiction?* Yes No (c) Have you ever surrendered a controlled drug registration or had a controlled drug registration revoked, suspended or denied in New Jersey, any other state, the District of Columbia or in any other jurisdiction?* Yes No (d) If the applicant is a corporation, association, or partnership: has any or employee who has access to controlled dangerous substances been convicted of a crime in connection with controlled substances under federal law or the laws of New Jersey, any other state, the District of Columbia or any other jurisdiction?* Yes No (e) If the applicant is a corporation, association, or partnership: has any shares or employee who has access to controlled dangerous substances surrendered a controlled drug registration, had a controlled drug registration suspended, revoked, or denied, or