State Form 34617 - State Application Indiana Controlled Substances Registration - Indiana
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1For official use only
STATE APPLICATION INDIANA CONTROLLED
CSR No.
SUBSTANCES REGISTRATION
State Form 34617 (R11 / 6-97)
Receipt No.
Approved by State Board of Accounts, 1996
Health Professions Bureau
Issuance date
402 West Washington St., Rm. 041
Indianapolis, IN 46204
Approval / Iss Coord.
Please refer to the enclosed instructions before completing for applicable fee and information.
Please type or print all information
PRACTITIONERS
(Please check one box)
Dentist
Physician
Osteopathic Physician
Podiatrist
Researcher
Veterinarian
Advanced Practice Nurse
Name of practitioner
Indicate speciality
Telephone number
Professional License number
Date of birth
Social Security number *
Name of Facility (if applicable)
* Your Social Security number is requested by this agency in accordance with
IC 4-1-8-1, and it is not mandatory that it be given. Social Security numbers are
available to the Indiana Department of Revenue.
Indiana practice address (may not be a P.O. Box)
City, State, Zip Code
Drug schedules: (Check all applicable)
1
2
2 Narcotic
3
3 Narcotic
4
5
If your answer is Yes to any of the following, explain fully in a signed and notarized statement, including all related details. Include the violation, location,
date and disposition. Letters from attorneys or insurance companies are not accepted in lieu of your statement. Falsification of any of the following is grounds
for permanent revocation of a registration issued pursuant to this application.
1. Has disciplinary action ever been taken regarding any health license, certificate, registration or permit that you hold or have held?
Yes
No
2. Have you ever been convicted of, pleaded guilty or nolo contendere to:
Yes
No
a. A violation of any federal, state or local law relating to the use, manufacturing, distribution or dispensing of controlled
substances or drug addiction?
Yes
No
b. To any offense, misdemeanor or felony in any state (except for minor violations of traffic laws resulting in fines)?
Signature of practitioner
Date
APPLICATION AFFIRMATION
I hereby swear or affirm under the penalties of perjury,
that the statements made in this application are true,
complete and correct.
NON-PRACTITIONERS
(Please check one box)
Hospital / Clinic
Surgery Center
Wholesale Distributor
Pharmacy
Analytical Laboratory
Manufacturer
Teaching Institution
Other: _________________________
(Please specify)
Name of Facility
DBA (if applicable)
Pharmacy manager or Person responsible for controlled substances
Address (may not be a P.O. Box)
City, State, Zip Code
Drug schedules: (Check all applicable)
1
2
2 Narcotic
3
3 Narcotic
4
5
If your answer is Yes to any of the following, explain fully in a signed and notarized statement, including all related details. Include the violation, location,
date and disposition. Letters from attorneys or insurance companies are not accepted in lieu of your statement. Falsification of any of the following is grounds
for permanent revocation of a registration issued pursuant to this application.
Has the applicant, any of the agents or listed pharmacist ever been convicted of, pleaded guilty or nolo contendere to:
a. A violation of any federal, state or local law relating to the use, manufacturing, distribution or dispensing of controlled
Yes
No
substances or drug addiction?
Yes
No
b. To any offense, misdemeanor or felony in any state (except for minor violations of traffic laws resulting in fines)?
Signature of applicant
Date
APPLICATION AFFIRMATION
I hereby swear or affirm under the penalties of perjury,
that the statements made in this application are true,
complete and correct.
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