Form Il486-1019 - Application For Licensure And/or Examination (Page 20 of 22) in pdf

Form Il486-1019 - Application For Licensure And/or Examination Page 20

INSTRUCTIONS FOR CONTROLLED SUBSTANCES REGISTRATION

****READ AND FOLLOW INSTRUCTIONS CAREFULLY****

If you hold a non-renewed controlled substances registration, you must

reinstate that registration. Do not apply for a new registration.

To expedite the processing of your controlled substances application,

SUBMIT THE APPLICATION AND FEE WITH YOUR PROFESSIONAL APPLICATION.

Every person who prescribes and/or stores and dispenses any controlled substances within the State of Illinois

must obtain a license issued by the Department of Financial and Professional Regulation in acordance with the

Illinois Controlled Substances Act.

A separate controlled substances registration is required for each place of professional practice or business where

controlled substances are stored or dispensed.

If you do not properly complete Parts I through VII (front and back) of the application, the application

will be returned to you and licensure will be delayed.

It is mandatory that the permanent mailing address and/or business address be a street address. P.O. boxes

are not acceptable. Your Controlled Substances registration must be issued to a street address.

If your professional application is pending, write "pending" in Part IV. A controlled substances registration

will not be issued until your professional license has been issued. A controlled substances registration will

not be issued to individuals holding a temporary license.

You must circle the drug schedules for which you are applying in Part III.

You must complete and submit the CCA Form. Your application will not be processed withouot completion

of this form.

Submit the $5 application fee. Make check or money order payable to the Department of Financial and

Professional Regulation (IDFPR). The fee is non-refundable. Mail the completed application and fee to:

Department of Financial and Professional Regulation

ATTN: Division of Professional Regulation

P.O. Box 7007

Springﬁ eld, Illinois 62791

A State controlled substances registration is a prerequisite for Federal controlled substances registration. The

address on your Illinois controlled substances registration must be exactly the same address as your Federal

registration. For information concerning Federal registration, you must contact:

Drug Enforcement Administration

230 South Dearborn, Suite 1200

Chicago, Illinois 60604

Telephone: 312/353-7875

Web site:

Additional application forms can be downloaded from the IDFPR Web site at

IL486-0500 8/16 (LT-INS)

Form Il486-1019 - Application For Licensure And/or Examination Page 20