227 Form – Fill Out and Use This PDF

FORM DHHS 227

Application for Reregistration

under

N.C. Controlled Substances Act

of 1971

DHHS Registration No. ___________________

DEA No. ___________________

Please print or type all entries

____________________________________________________

Name of Applicant (Facility Name)

_________________________________________________________

Mailing Address

_________________________________________________________

Location

_________________________________________________________

TownCountyStateZip

Applicant Telephone: ___________________________________________

Area Code

Point of Contact Name: ________________________

Point of Contact Telephone: _____________________

RETAIN COPY

Mail Application to:

Department of Health and Human Services

Controller’s Office-Accounts Receivable

2025 Mail Service Center

Raleigh, North Carolina 27699-2025

Telephone: (919) 733-1765

A

Dog Handler $150

2.Drug Schedules: (Check all applicable)

Schedule IIN Non-narcotic

Schedule III

Narcotic

Schedule IIIN Non-narcotic

Schedule IV

Schedule V

Schedule VI

3.Registration as a manufacturer conveys distribution privileges only as those substances manufactured.

Manufacturers (Item 1A, Business Activity) check schedules applicable to any category in the boxes below:

Repacker-Relabeler

4.ALL APPLICANTS MUST ANSWER THE FOLLOWING:

(a)Are you currently authorized to manufacture, distribute, dispense, prescribe, conduct research, or otherwise handle the controlled substances in the schedules for which you applying under the laws of North Carolina or the Federal Government?

(b)Has the applicant been convicted of a felony under State or Federal law relating to the manufacture, possession, distribution, or dispensing of controlled substances?

Yes No

(c)Has any previous registration held by the applicant, corporation, firm, partner, or officer of applicant under Federal CSA or NCCSA been surrendered, revoked, suspended, denied, or is it pending such action?

If YES to b and/or c, attach a letter setting forth the circumstances of such action.

5. Drug code numbers must coincide with the schedules requested, listed below are the drug code requirements for each business activity:

Analytic Lab – Not Required To List Drug Codes

Distributor – Schedule I

Researcher – Schedule I, II, III, IV, V and VI

Manufacturer – Schedule I, II, III, IIIN