Controlled Substance Registration Application | Pdf Fpdf Docx | District Of Columbia

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Controlled Substance Registration Application | Pdf Fpdf Docx | District Of Columbia

Controlled Substance Registration Application

This is a District Of Columbia form that can be used for Pharmaceutical Control within Statewide, Health And Licensing Administration.

Alternate TextLast updated: 9/11/2018

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899 North Capitol Street NE | 2nd Fl, Washington, DC 20002 | P 202-724-8800 | F 877-862-4252 | https://dchealth.dc.gov/pcd CHECKLIST FOR SUBMITTING NEW AND RENEWING DC Controlled Substance Drug Registration Application (Manufacturers, Distributors, Wholesalers - Facilities) IMPORTANT PLEASE READ Every person who manufactures, distributes, dispenses, or conducts research with any controlled substance, or who proposes to engage in the manufacture, distribution, dispensing, or conducting of research with any controlled substance within the District of Columbia shall obtain (biennially) and maintain current registration. (24722-1002.1 - DCMR Chapter 10) Mail completed application(s), nonrefundable fee(s) and required documents together to DC DOH - Pharmacy Division, P.O. Box 37803, Washington, DC 20013. CHECKLIST FOR SUBMITTING THE DC CONTROLLED SUBSTANCE REGISTRATION APPLICATION FOR SCHEDULES II V DRUGS: Controlled Substance Registration Application completed, dated and signed $130.00 nonrefundable fee (check or money order), made payable to DC Treasurer Copy of current U.S. Federal DEA Registration for the location (cannot be expired) List of all controlled substance drug products applicant intends to ship into the District of Columbia IMPORTANT: A separate application, fee and required documentation are required to be submitted for Schedule I drug products. Requirements are listed below. CHECKLIST FOR SUBMITTING THE DC CONTROLLED SUBSTANCE REGISTRATION APPLICATION FOR SCHEDULE I DRUGS: Controlled Substance Registration Application completed dated and signed $130.00 nonrefundable fee (check or money order), made payable to DC Treasurer Copy of U.S. (Federal) DEA Registration for Schedule I for the location (cannot be expired) List of Schedule I controlled substance drug products applicant intends to ship into the District List of company names and complete addresses of customers to which the applicant intends to ship Schedule I controlled substance drugs in the District of Columbia Detailed explanation for intended use of Schedule I controlled substances drug products An in state (Resident) applicant must also submit the IRB Safe with CRF Standards for Schedule I controlled substance drugs Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 899 North Capitol Street NE | 2nd Fl, Washington, DC 20002 | P 202-724-8800 | F 877-862-4252 | https://dchealth.dc.gov/pcd CHECKLIST FOR SUBMITTING NEW AND RENEWING DC Controlled Substance Drug Registration Application (Manufacturers, Distributors, Wholesalers Facilities) RECORD KEEPING: Please make a copy of the completed application, payment(s) and all documents submitted with the application for your records. Mail to: DC HEALTH - PHARMACY DIVISION P.O. Box 37803 Washington, DC 20013 LICENSE VERIFICATION: To verify the status of a DC controlled substance registration application, renewal, or license/registration, paste the web link below into your web browser: https://app.hpla.doh.dc.gov/Weblookupcs/Search.aspx?facility=Y SUBMITTING APPLICATION(S): When submitting multiple applications, it is the sole responsibility of the applicant to submit each application with the required fee(s) and document(s). The fee and documents must be securely attached to the respective application, as outlined in the checklist, and submitted in the order of the checklist.. FREQUENTLY ASKED QUESTIONS: A list of frequently asked questions can be located on the DC government website at https://dchealth.dc.gov/pcd . DC WEBSITE: DC Applications, Forms, Checklists and Municipal Regulations are available online at https://dchealth.dc.gov/pcd . IMPORTANT: The application, nonrefundable fee and all required documents must be submitted together. Incomplete applications or those submitted with missing, expired, or unreadable documents will be returned . Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 1 899 North Capitol Street NE | 2nd Fl, Washington, DC 20002 | P 202-724-8800 | F 877-862-4252 | https://dchealth.dc.gov/pcd CONTROLLED SUBSTANCE REGISTRATION APPLICATION FOR FACILITIES Mail application, nonrefundable fee of $130, US (federal) DEA Registration, and all required documents to: DC HEALTH - PHARMACY DIVISION, P.O. Box 37803, Washington, DC 20013 https://www.dchealth.dc.gov/pcd Please print clearly in ink and in upper case letters only. Incomplete applications and those submitted with incorrect, missing, or expired documents will be returned via regular US mail Application Type New Change of Name Ch ange of Ownership Change of Location Renew al (Provide Controlled Substance Registration number): F acility Location Out - of - S t ate (Non - Resident) In State (Resident) Profession Type Pharmacy Distributor Wholesaler Substance Abuse Facility Researcher Veterinary Clinic Fire and EMS Other ( s pecify below) Choose Controlled Substance Schedules applicant is applying for: Schedule II Schedule IIN Schedule III Schedule IIIN Schedule IV Schedule V A pplicant Information Name of Applicant (Legal Name of Business ) Street No. Street Name Suite No. City State Zip Code Cell Phone Number E - Mail Address for Applicant Provide Facility L ocation Address on t his Page American LegalNet, Inc. www.FormsWorkFlow.com 2 899 North Capitol Street NE | 2nd Fl, Washington, DC 20002 | P 202-724-8800 | F 877-862-4252 | https://dchealth.dc.gov/pcd Mailing Address ( If Differe nt ) or DC Business Affiliation (Required for Researchers and Resident Health facilities) Street No. Street Name Suite No. City State Zip Code Work Phone Number Fax Number E - Mail Address All Applicants must answer the following questions; Any question that does not apply to the applicant must be answered as N/A . A. If the applicant is a corporation, association or partnership, has any officer, partner, stockholder or proprietor been convi c ted of a felony in connection with controlled substance under District of Columbia, State or Federal law? Yes No B. Has the applicant been convicted of a felony in connection with controlled substance (CS) under DC, State or Federal Law? Yes No If the answer is Yes , submit a written explanation. C. Has the applicant ever surrendered or had a controlled substance registration revoked, suspended or denied? Yes No If the answer is Yes , submit a written explanation. I CERTIFY THAT, TO THE BEST OF MY KNOWLEDGE , ALL OF THE STATEMENTS MADE ARE TRUE, COMPLETE AND CORRECT. Signature of Applica nt/Authorized Individual Print Name and Title Submit application, n onrefundable f ee U.S. ( Federal ) DEA Regis tration, and list of all controlled substance drug products the applicant intends to ship to or within the District of Columbia. Mail to: DC HEALTH - PHARMACY DIVISION P.O.BOX 37803 WASHINGTON, DC 20013 Note: Applicants seeking fee waiver under 22DCMR Chapter 10, Section 1005.1 (a - d) complete the certification of fee exemption form attached . American LegalNet, Inc. www.FormsWorkFlow.com 3 899 North Capitol Street NE | 2nd Fl, Washington, DC 20002 | P 202-724-8800 | F 877-862-4252 | https://dchealth.dc.gov/pcd TO THE APPLICANT: (Please read and complete all fields below) Please read carefully and completely before signing. A false statement on this certification requires that the Department pro ceed immediately to revoke the license or permit for which you are now applying and fine you $1000.00. This certificate is required - 118, D.C. Code 24747 - 2861 et seq.) I,, certify that as of , I do not owe more than $100.00 to th e District of Columbia government Print Name as a result of: 1. Fines, penalties or interest assessed pursuant to the Litter Control Administr ation Action of 1985, effective March 25, 1986 (D.C. Code 247 6 - 2901 et seq.); 2. Fines, penalties or interest assessed pursuant to the Illegal Dumping Enforcement Act of 1994, effective May 20, 1994 (D.C. Law 10 - 117; D.C. Code 247 6 - 2911 et seq.); 3. Fines, penalties or interest assessed pursuant to the Department of Consumer and Regulatory Affair Civil Infractions Act of 1985, ef fective October 5, 1986 (D.C. Law 6 - 42; D.C. Code 247 6 - 2701 et seq.); or 4. Past due taxes. I understand that if I knowingly falsify this Certification, the Department will mov

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