Form Dhhs 224-F - Animal Shelter Application For Registration

Download a blank fillable Form Dhhs 224-F - Animal Shelter Application For Registration in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Dhhs 224-F - Animal Shelter Application For Registration with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

Animal Shelter Application for Registration

(Form DHHS 224-F)

NC Department of Health and Human Services

Division of Mental Health, Developmental Disabilities, and Substance Abuse Services – Drug Control Unit

3008 Mail Center Service Center

Raleigh, North Carolina 27699-3008

(919) 733-1765

Application Instructions – PLEASE READ THESE INSTRUCTIONS CAREFULLY

This application will be used by the North Carolina Department of Health and Human Services’ Drug Control Unit to initiate a registration for the

applicant under the North Carolina Controlled Substances Act of 1971 as well as assist in determining whether or not the applicant is in compliance

with State and Federal laws pertaining to controlled substances. Therefore, please fill out this application in its entirety. Do not leave any fields blank,

rather indicate that a field is not applicable by typing “N/A” in the space provided. Failure to complete the entire form will result in the application

being returned to the applicant along with a request for additional information. To submit this Application for Registration, e-mail both the completed

electronic PDF and a signed PDF copy to

nccsareg@dhhs.nc.gov

along with a signed PDF copy of an Applicant Disclosure of Loss, Diversion, or

Destruction of Controlled Substances (Addendum to Forms DHHS 224 and 225). In accordance with 10A NCAC 26E.0104, the applicant must also

submit a required, nonrefundable application fee in the amount of $150.00.

Attestation

By signing below, you attest that you are an administrator or an agent of the applicant who is authorized to answer the questions presented in this

document. Furthermore, you attest that all of the information provided on this form is true, accurate, and complete to the best of your knowledge. All

responses are subject to verification by the North Carolina Department of Health and Human Services’ Drug Control Unit.

Date

Signature

Phone Number

Name and Title

E-Mail Address

Section A - Applicant Information

Facility Name

Facility’s Address

Facility’s County

Facility’s State, City, Zip

Mailing Address

Facility’s Phone Number

Mailing State, City, Zip

Administrator Name:

Title:

Section B - Registration Classification

B1. Check all applicable drug schedules in which you are applying for:

☐ Schedule II (Narcotic)

☐ Schedule III (Narcotic)

☐ Schedule IV

☐ Schedule IIN (Non-narcotic)

☐ Schedule IIIN (Non-narcotic)

☐ Schedule V

By default, Animal Shelters may only be granted Schedules II, IIN, III, and/or IIIN. If Schedule IV or V are needed, the applicant must submit a letter

with this application that states the controlled substances in those Schedules that the facility wishes to stock and the reason why they’re necessary.

B2. Are you currently authorized to manufacture, distribute, dispense, prescribe, conduct research, or

☐ Yes

☐ No

otherwise handle controlled substances in the schedules for which you are applying under the laws of

North Carolina or the Federal Government?

B3. Has the applicant been convicted of a felony under State or Federal law relating to the manufacture,

☐ Yes

☐ No

possession, distribution, or dispensing of controlled substances?

B4. Has any previous registration held by the applicant, corporation, firm, partner, or officer of applicant

☐ Yes

☐ No