Form Dhhs 225 – Fill Out and Use This PDF

FORM DHHS 225

____________________________________________________

Point of Contact Name: ________________________

Name of Applicant (Facility Name)

Application for Registration

_________________________________________________________

Point of Contact Telephone: _____________________

under

Mailing Address

RETAIN COPY

N.C. Controlled Substances Act

_________________________________________________________

Mail Application to:

of 1971

Location

_________________________________________________________

Department of Health and Human Services

DHHS Registration No. ___________________

Division of Mental Health/DD/SA Services

Town

County

State

Zip

Drug Control Unit

DEA No. ___________________

Applicant Telephone: ___________________________________________

3008 Mail Service Center

Raleigh, North Carolina 27699-3008

Area Code

Telephone: (919) 733-1765

Please print or type all entries

REGISTRATION CLASSIFICATION: SUBMIT CHECK OR MONEY ORDER PAYABLE TO: SUBSTANCE ABUSE DRUG REGULATORY

1. Business Activity: (Check one only)

A

Manufacturer $600

B

Distributor $500

C

Researcher $125

D

Analytical Laboratory $100

E

Dog Handler $150

2. Drug Schedules: (Check all applicable)

Schedule I

Schedule II

Schedule IIN

Schedule III

Schedule IIIN

Schedule IV

Schedule V

Schedule VI

Narcotic

Non-narcotic

Narcotic

Non-narcotic

3. Registration as a manufacturer conveys distribution

4. ALL APPLICANTS MUST ANSWER THE FOLLOWING:

privileges only as those substances manufactured.

(a)

Are you currently authorized to manufacture, distribute, dispense, prescribe, conduct research, or otherwise handle the controlled substances in the schedules for which

Manufacturers (Item 1A, Business Activity) check schedules

you applying under the laws of North Carolina or the Federal Government?

Yes

No

applicable to any category in the boxes below:

(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

Schedules

(c)

Has any previous registration held by the applicant, corporation, firm, partner, or officer of applicant under Federal CSA or NCCSA been surrendered, revoked,

I

II

III

IV

V

VI

suspended, denied, or is it pending such action?

Bulk Manufacturer

Yes

No

Synthesizer-Extractor

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

Dosage Form

Manufacturer

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

Repacker-Relabeler

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

IF ADDITIONAL SPACE IS REQUIRED, USE A SEPARATE SHEET AND RETURN WITH APPLICATION

AUTHORIZED INDIVIDUAL

__________________

________________________________

_________________________________

______________________________

Date

Print or Type Name

Signature

Official Title