Limited Controlled Substance Registration Application


New Mexico Regulation and Licensing Department
Board of Pharmacy
5500 Sa n An ton io Dri v e N E, S u it e C ▪ A lb uq uer qu e, N ew Mexi co 871 09
( 505) 222 -9830 ▪ Fax ( 505) 222 -9845
▪ ( 800) 565 -91 02
h tt p :/ / ld .s ta t e.nm .us /b oa r ds/ ph a rma px
Limited Controlled Substance Registration Application
Check a box:
[ ] New Application
[ ] Change of ownership (Old license Number: CS______________)
Analytical Lab
Teaching Institute
Registration Class: (√ mark ONLY one)
Name and Mailing Address:
Physical Location Address: (If different then mailing)
Telephone Number: _______________
Fax Number: _________________
E-Mail: _________________________________
List all trade or business names (“DBA” names) previously or currently used by same corporation or by licensee:
Schedule of Drugs: (√ mark schedules that are needed)
Initial Controlled Substance Research Applicants MUST submit the following:
Policies and Procedures manual that MUST include the following:
Names of all individuals with access
Security locked, substantially constructed cabinet Drug Procurement
Drug storage area
Invoices, receipts, and logs to be kept Drug source
Describe the lock system
Forms to indicate destruction (DEA Form 41) for destruction
Drug Usage
Required May 1 of each year Research Protocol
Wastage to be kept on a memorandum report, to be kept with licensees controlled substance
Drug Storage Conditions
Theft or unexplained loss procedure (DEA Form 106) Inventory Date (annual)
Records or logs to be used for
If any person with access to drugs resigns is dismissed, fired, or otherwise, leaves employment,
accountability Drug
notification to the Board is required in writing within ten (10) days.
Required May 1 of each year
Initial applications should contact a Board inspector to review the application procedure
Research Protocol
and discuss any additional requirements necessary for licensure
I/we have not since the time of our initial licensure or last renewal, been arrested, investigated for, charged with, convicted of, sentenced, entered a plea of
nolo contendere, or entered into any other legal agreements for any criminal offense in any state, territory or possession of the United States or by the
federal government.*
I/we have not since the time of our initial licensure or last renewal, had any disciplinary actions, or has any professional licensing authority investigated any
pending actions against us, or to my knowledge.*
*Please explain any failure to sign the statements above. Explain the circumstances, include a copy of the judgment, and attach to this application.
I/we certify under penalty of perjury that the information given in this application is true and accurate to the best of my (our) knowledge.
Printed Name and Title
The chart shows when your controlled substance number will expire. New Mexico charges $5.00 per month for this registration since the
first year is prorated. The first letter of your last name determines the month in which your license number will expire; please submit
only the amount of money required from the current month through the month that appears below next to the first letter of your last
name. *If the amount is $15 or less please also include an additional $60 to cover the prorated year and the full year.
*Mail check or money order payable to New Mexico Board of Pharmacy to the address above.
January - M
April – Q, R
July - B
October – H, N
February - S
May – U, V, W, X, Y, Z
August – C, E
November – I, T
March – L, P
June – A, D
September – F, G
December – J, K, O
Please make sure that everything is filled out and signed before returning to us.
Revision date: 08/2015


00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal