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 Ofce of the Attorney General
Drug Control Unit
P.O. Box 45045
Newark, NJ 07101
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, or have you been permitted to surrender or otherwise
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
Dispenser/Prescriber (check category)
A.P.N. (Advanced Practice Nurse)
C.N.M. (Certied Nurse Midwife)
P.A. (Physician Assistant)
Initial Application for Registration
for Dispenser/Prescriber
Mid-Level Practitioner
New Jersey Controlled Dangerous Substances Act
N.J.S.A. 24:21-1 et seq.
Dispenser/Prescriber Identifying Data
1. New Jersey license number ______________________________________
2. Mid-Level practitioners are required to collaborate with and/or be supervised
by physicians, consistent with agreed upon parameters of their respective
practices. As concerns the prescribing and/or ordering/dispensing of C.D.S., by
afxing my signature below, I afrm that required oversight regarding C.D.S.
exists between me and a duly authorized active New Jersey physician licensee.
I understand that any C.D.S. ordering/dispensing/prescribing without the required
collaborative or supervisory oversight, or engaging in any violation of the statutes or
regulations regarding the ordering/dispensing/prescribing of C.D.S. may be deemed
professional misconduct or grounds for disciplinary sanction within the meaning
of N.J.S.A. 45:1-21.
___________________________
Applicant's signature
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 certication or license or certicate
renewal.
*Pursuant to N.J.S.A. 2A:17-56.44e of the New Jersey child support enforcement law,
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 notied that under the Federal Privacy Act (5 U.S.C. Section 552a (note (b)),
the Unit or licensing agency 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 ofcials and agencies of information obtained in investigations pertaining
to licensure or certication 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.
Certication
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 sufcient 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 qualications 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
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