Application For Authority To Dispense Drugs - Nevada State Board Of Pharmacy Page 4
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4Include with the Application for Authority to Dispense Drugs
Practitioner Dispensing
Controlled Substance Waiver Form
Each dispensing practitioner must complete this form. Do not submit for a group.
Print Name:
Address:
City:
State: NV
Zip:
Telephone:
I will be dispensing controlled substances at the address listed above and I understand that I
am required and submit data to the Prescription Controlled Substance Abuse Prevention Task Force
weekly as required by NAC 639.745 [1(f)].
I will not be dispensing controlled substances at the address listed above. If I choose to
dispense controlled substances in the future, I must contact the Nevada State Board of Pharmacy to
modify my license.
By signing and dating this waiver form, I certify that the information provided is true.
Original Signature of Dispensing Practitioner
Date
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