DDC-25
Revised 3/19
Retain the last copy for your records. Mail the remaining copies with your fee to the above address.
Make the check or money order payable to: State of New Jersey
For State USe only
C.D.S. number________________________ Effective date ___________________________ Expiration date ______________________
New Jersey Ofce of the Attorney General
Drug Control Unit
P.O. Box 45045
Newark, NJ 07101
Please type or print clearly.
Section A: All of the items in this section must be completed.
1.
Provide the applicant’s name and the place of business to be registered (do
not use solely a P.O. box). Registration will be provided for New Jersey
locations only. If the registration is for a University of Medicine and
Dentistry of New Jersey facility, include the department, room number,
designation, e.g. MEB, MSB, etc. The address of record must be your
pharmacy/facility location.
________________________________________________________
Pharmacy permit trade name
________________________________________________________
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)
Note: 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 ($40)
3. Registration requested in the following Schedule(s):
Schedule
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
Sched
ule 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) If the applicant is a corporation, association, or partnership: has any
ofcer, partner, stockholder holding 10% or more of the outstanding shares
or employee who has access to controlled dangerous substances been
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
(e) If the applicant is a corporation, association, or partnership: has any
ofcer, partner, stockholder holding 10% or more of the outstanding
shares or employee who has access to controlled dangerous substances
surrendered a controlled drug registration, had a controlled drug
registration suspended, revoked, or denied, or owned or worked
for an entity which has surrendered or had revoked, suspended, or
denied a controlled drug registration under federal law or the laws
of New Jersey, any other state, the District of Columbia or any other
jurisdiction?* Yes No
* If "Yes," attach a letter setting forth the circumstances of such action.
Initial Application for Registration
for Dispenser – Pharmacy
New Jersey Controlled Dangerous Substances Act
N.J.S.A. 24:21-1 et seq.
Section B: Pharmacy Licensure Information
Pharmacy permit number _____________________________________
Section C: Business Information
1. List the name, address and telephone number of the person who has
administrative or managerial responsibility for the registered location.
2. List the name, address and telephone number of the registered agent (if a
corporation) or the name and address of the New Jersey resident upon whom
process may be served (if a nonresident proprietor or partner).
Section D: Certication
I, _____________________________________ being duly sworn, depose
and say under penalty of false statement, that I am the person described and
identied intis application; that the information given in this application and
all submitted materials contain no willful misrepresentations and that the
information is true and complete. I understand that should an investigation
at any time disclose otherwise, my application may be rejected, and I may
face legal sanctions if I am already registered. I understand that in signing
this application for registration, I am consenting to any reasonable inquiry
that may be necessary to verity the information that I have provided on this
form or may provide in conjunction with this application.
____________________________________________
Applicant's signature
____________________________________________
Date
click to sign
signature
click to edit
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