Form Cpcsp 01 – Fill Out and Use This PDF

Controlled Substance Registration for Practitioner

This application must be accompanied by a check or money order in the amount of $40.00, made payable to “TREASURER, STATE OF CONNECTICUT." Upon approval of your application, a registration certificate will be mailed with the effective date of when your application is approved. All registrations expire biennially on February 28th.

Return your completed application and fee to:

Department of Consumer Protection, License Services Division, 165 Capitol Avenue, Hartford, CT 06106

First Name		Middle Initial		Last Name					Title
Residence Street Address				City				State	Zip Code
Telephone Number	Social Security Number	Email Address					Date of Birth		Male
									Female
Practice Site Name (Physician’s Office, Hospital, Long-Term Care Facility, etc.)
Street Address				City				State	Zip Code
Mailing Address to where all correspondence should be directed:			Residence		Practice Site	Other (as indicated below)
Street Address				City				State	Zip Code

Registration Classification: Check () only one

Drug Schedules:
Schedule I (RESEARCH)	Schedule II	Schedule III		Schedule IV	Schedule V
Is this application to register as a Medical Director at a Long-Term Care Facility?			Yes	No

If certified by a specialty board approved by the American Board of Medical Specialties (ABMS), indicate the name of the board and specialty. American Board Of: ___________________________________________________________ Specialty: ____________________________________

Has the applicant ever been convicted of any criminal charge under Federal or State controlled drug laws?	Yes	No If yes, attach a
statement of explanation.

Has any Federal or State registration held by the applicant been surrendered, revoked, suspended, limited, denied or is any such action pending?

Yes	No If yes, attach a statement of explanation.

FOR FEE EXEMPT ONLY: If the applicant is an officer or employee of a Federal, State or Municipal Government agency who is exempt

from payment of the registration fee, please complete the following. The registration fee is required if the applicant prescribes, administers or dispenses controlled substances in any capacity not related to his/her Governmental duties. Signature of a supervisor is required for exemption.

Name of Facility or Government Agency: _____________________________________________________________________________________

Address: ________________________________________________________________________________________________________________

Supervisor’s Signature: __________________________________________________________ Title: __________________ Date: _____________

I have read the above statement and it is true to the best of my knowledge. I fully understand that if I knowingly make a statement that is untrue and which is intended to mislead the Commissioner of Consumer Protection or any person designated by the commissioner in the performance of their official function, I will be in violation of Section 53a-157b of the Connecticut General Statutes.

______________________________________________________________________	______________________
Signature of Applicant	Date