Fillable Controlled Dangerous Substance Registration (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Controlled Dangerous Substance Registration (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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  • 23 check-boxes
  • 16 other fields

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
Drug Control Unit
124 Halsey Street, 3rd Floor, P.O. Box 45045, Newark, NJ 07101
(973) 504-6351
Controlled Dangerous Substance Registration
Instruction sheet
Enclosed is a Controlled Dangerous Substance (C.D.S.) application, which you are required to submit pursuant to N.J.S.A. 24:21-1 et
seq. Registration is required for every person who, or rm that, manufactures, prescribes, distributes, dispenses or conducts research or
analysis utilizing controlled dangerous substances.
A New Jersey C.D.S. registration is issued only for a New Jersey location. Be sure to include a $40.00 check or money order,
payable to “State of New Jersey.” It will take 4-6 weeks to process this application. Your C.D.S. registration will be mailed to
the mailing address on le with your professional licensing board.
Please note:
1. If you have a current D.E.A. number in another state and plan to discontinue practice in that state, you may transfer that D.E.A.
number to New Jersey by providing the following to the Drug Enforcement Administration, 80 Mulberry Street, Newark, New Jersey
07102, (888-356-1071) www.deadiversion.usdoj.gov:
a. a copy of your New Jersey professional license or a verication letter from the licensing board;
b. a copy of your New Jersey C.D.S. registration or a verication letter;
c. a copy of your out-of-state D.E.A. registration; and
d. a letter requesting an address change to the same address that is on your New Jersey C.D.S. registration.
A D.E.A. number is only valid in the state listed on the certicate.
2. If you plan to practice in both New Jersey and the state(s) where you currently hold a D.E.A. registration(s), you must also obtain
a D.E.A. registration for New Jersey. Please contact the D.E.A. at the address indicated above and complete the New Jersey
application.
3. In order to complete the attached application, please note:
a. A dispenser/prescriber/ practitioner includes medical doctors, doctors of osteopathy, dentists, optometrists, veterinarians, and
podiatrists. A mid-level dispenser/prescriber/practitioner includes physician assistants, advanced practice nurses and certied
nurse midwives. Pharmacies must complete a separate application.
b. Every person or rm handling controlled dangerous substances in New Jersey is required to have both a state and federal
registration for that purpose. Federal facilities do not require registration.
c. The address supplied must be current and an actual location where controlled dangerous substances will be stored, prescribed,
dispensed, etc. The address cannot be solely a post ofce box.
d. Dentists and optometrists may only register at the address for which they hold a current registration issued by their board and
at which the C.D.S. registration is required pursuant to 3(c) above.
e. Individual practitioner applicants (medical doctors, dentists, veterinarians, etc.) must use their own name, not professional
association/corporation or partnership information.
f. Pharmacies are required to use their common trading name (e.g. David Pharmacy), not a business or corporate name.
g. Dispensers/Prescribers must have an active and current New Jersey professional license number. Please write in your New
Jersey professional license number in “Section B” of the application.
• Advanced Practice Nurses may prescribe controlled dangerous substances, but may not purchase or maintain any stock
supplies of any C.D.S. medication.
• Optometrists are authorized to prescribe/dispense only Schedule III, IV and V controlled substances and must have an
O.M. number registered with their board.
4. If more space is required for your response to any question on the application, please submit a separate sheet of paper identifying
the section(s) to which you are responding.
If we can be of further assistance, please call 973-504-6351.
3/19
Initial Application for Registration
for Dispenser/Prescriber


 Dispenser/Prescriber(checkcategory)
1.  M.D. 3.  Dentist 5. Podiatrist
2.
 D.O. 4. Veterinarian 6. Optometrist
Licensenumber_____________________________________

1.YoumustalsoobtainaD.E.A.registrationforthesameNewJerseyaddressofrecord.
2.DentistsandoptometristsmayonlyregisterataNewJerseyaddressforwhich
theyholdacurrentregistrationissuedbytheirboard.
3.Musthaveanactive/currentNewJerseyprofessionallicense.
 Dispenser/PrescriberIdentifyingData
3.*SocialSecurityNumber:________ -_______ - ________
YoudiscloseyourSocialSecuritynumberforthereasonsstatedbelow.Failure
todosomayresultinadenialoflicensureorcerticationorlicenseorcerticate
renewal.
*PursuanttoN.J.S.A.2A:17-56.44eoftheNewJerseychildsupportenforcementlaw,
N.J.S.A.54:50-25oftheNewJerseytaxationlawandSection1128E(b)(2)Aofthe
SocialSecurityAct,theUnitorlicensingagencytowhichthisformissubmittedis
requiredtoobtainyourSocialSecuritynumber.IfyoudonothaveaSocialSecurity
number,theUnitmustascertainthereasonthatyoudonothaveone.TheUnitis
furtherobligatedtoprovideyourSocialSecuritynumbertotheDirectorofTaxation,
theProbationDivisionorotheragencyresponsibleforchildsupportenforcement
andtheH.I.P.DataBankwhenreportingadverseactions.
Youarealsobeingaskedtoconsent,onavoluntarybasis,totheuseofyourSocial
Securitynumberfortheadditionalreasonsstatedbelow.
YouarenotiedthatundertheFederalPrivacyAct(5U.S.C.Section552a(note(b)),
theUnitorlicensingagencytowhichthisformissubmittedisrequestingthevoluntary
disclosureofyourSocialSecuritynumber.Ifyougiveyourconsentfortheuseof
yourSocialSecuritynumber,itmaybeused:toverifytheidentityofanapplicant,
toaidinthecollectionofnancialobligationsdueandowingtheUnitoranyother
stateagency,andtoaidin thedisclosuretostateorfederallawenforcementand
licensingofcialsandagenciesofinformationobtainedininvestigationspertaining
tolicensureorcerticationanddisciplinaryproceedings.
I,_______________________________ ,
Consent DoNotConsent
Applicant’ssignature
totheuseofmySocialSecuritynumberforanyoftheadditionalpurposessetforth
above.IunderstandthatmyconsentisvoluntaryandthatifIdonotconsent,no
adverseactionorinferencewillbetakenordrawn.
 Certication
I,______________________________________ in making this application for
registration,certifythatIamtheapplicantandthatalloftheinformationprovidedin
connectionwiththisapplicationistruetothebestofmyknowledgeandbelief.I
understandthatanyomissions,inaccuraciesorfailuretomakefulldisclosuresmay
bedeemedsufcienttodenyregistrationortowithholdrenewaloforsuspendor
revokearegistrationissuedbytheDrugControlUnit.
Ivoluntarilyconsenttoathoroughinvestigationofmypresentandpastemployment
andotheractivitiesforthepurposeofverifyingmyqualicationsforregistration.I
furtherauthorizeallinstitutions,employers,agenciesandallgovernmentalagencies
andinstrumentalities(local,state,federalorforeign)toreleaseanyinformation,les
orrecordsrequestedbytheDrugControlUnit.
Icertifythat theforegoingstatementsmade bymearetrue. Iamaware that if
anyofthe foregoingstatementsmade by mearewillfully false,Iamsubject to
punishment.
_________________________________ ________________
Applicant'sfullsignature Date
DDC-25
Revised3/19
Retain a copy for your records. Mail the original and one copy with your fee to the above address.


For State USe only
C.D.S.number________________________ Effectivedate ___________________________ Expirationdate______________________
New Jersey Ofce of the Attorney General



Please type or print clearly.
 Alloftheitemsinthissectionmustbecompleted.
1.
Providetheapplicant’snameandtheplaceofbusiness(or,ifunavailable,
theNewJerseyresidence)toberegistered(donotusesolelyaP.O.box).
Ifthe
registrationisforaUniversityofMedicineandDentistryofNewJersey
facility,includethedepartment,roomnumber,designation,e.g.M.E.B.,
M.S.B.,etc.Theaddressofrecordmustbeyourpracticelocation.
________________________________________________________
Lastname Firstname MI
C.D.S.–ResponsibleIndividual
________________________________________________________
Department Roomnumber
________________________________________________________
Streetaddress
________________________ NewJersey ____________________
City ZIPcode
__________________________ __________________________
Hometelephonenumber(includeareacode) Businesstelephonenumber(includeareacode)
Please note that the above-registered address is subject to inspection pursuant to N.J.S.A. 24:21-31 & 32.
2. Registrationrequestedas: Dispenser/Prescriber($40)
3. Registrationrequestedfor: SchedulesIIthroughV
IfregistrationisbeingrequestedforonlycertainSchedules,please
indicatewhichSchedules: II III IV V
4. (a) Hasanyrestrictionbeenimposedwhichwouldaffectyourprivilege
toholdacontrolleddangeroussubstances(C.D.S.)registrationfor
ScheduleII,III,IVorVsubstancesinNewJersey,anyotherstate,
theDistrictofColumbiaorinanyotherjurisdiction?*
Yes No
(b)Have you been arrested, indicted or convicted of a crime in
connectionwithcontrolledsubstancesunderfederallaworthelaws
ofNewJersey,anyotherstate,theDistrictofColumbiaoranyother
jurisdiction?
Yes No
(c) Haveyoueversurrenderedacontrolleddrugregistrationorhada
controlleddrugregistrationrevoked,suspendedordeniedinNew
Jersey, any otherstate, the District of Columbiaor in anyother
jurisdiction?
Yes No
(d)ArethereanycriminalchargesagainstyouinNewJersey,anyother
state,theDistrictofColumbiaorinanyotherjurisdiction
Yes No
(e) Areyouawareofanyactionnowpendingagainstyourprofessional
license,orhaveyoubeenpermittedtosurrenderorotherwiserelinquish
yourprofessional license to avoid aninquiry or investigationin
NewJersey,anyotherstate,theDistrictofColumbiaorinanyother
jurisdiction?
Yes No

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Controlled Dangerous Substance Registration (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 15 August 2020

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