Form 08-4028d - Advanced Nurse Practitioner Application For Authorization To Prescribe And Dispense Controlled Substances

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NUR
FOR OFFICE USE ONLY
ALASKA BOARD OF NURSING
DEPARTMENT OF COMMUNITY AND ECONOMIC DEVELOPMENT
DIVISION OF OCCUPATIONAL LICENSING
STATE OFFICE BUILDING
333 WILLOUGHBY AVENUE, 9TH FLOOR
P.O. BOX 110806
JUNEAU, ALASKA 99811-0806
Fax (907) 465-2974
E-mail: license@dced.state.ak.us
If your last name begins with A – K, contact (907) 465-2544
If your last name begins with L – Z, contact (907) 465-2648
ADVANCED NURSE PRACTITIONER APPLICATION FOR AUTHORIZATION
TO PRESCRIBE AND DISPENSE CONTROLLED SUBSTANCES
$ 50.00 Application Fee
Attach a check or money order payable to the State of Alaska in the amount of $50.00 for the nonrefundable application fee.
In addition to the legend drug prescriptive authority authorized in 12 AAC 44.440, the board will, in its discretion, authorize an Advanced
Nurse Practitioner to prescribe and dispense Schedule 2-5 controlled substances in accordance with the applicable state and federal laws
(12 AAC 44.445).
You must have the equivalent of one year of experience prescribing legend drugs within five years prior to this application.
1.
Name:
Last
First
M.I.
2.
Mailing Address:
Telephone No.:
3.
Business Address:
Telephone No.:
4.
Alaska ANP Number:
5.
Date of Birth:
6.
Social Security Number:
Required by AS 08.01.060. (The department is not
authorized to issue a license, unless the applicant’s Social Security Number has been provided.)
7.
ANP Prescribing Experience:
Briefly describe your experience prescribing drugs during the past five years. Include the period of time you have been actively
prescribing and the types of drugs.
I,
, hereby certify that this information is true and correct
to the best of my knowledge. I understand that any false or misleading information in this application or accompanying documents may
result in failure to obtain authorization or subsequent revocation of my authorization to practice as an Advanced Nurse Practitioner.
SIGN HERE
Signature of Applicant
SUBSCRIBED AND SWORN before me this
day of
, 20
.
SIGN HERE
Signature of Notary Public
SEAL
Notary Public in and for the State of
My Commission Expires:
08-4028d (Rev. 8/00)

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