Nar 77 78 Form – Fill Out and Use This PDF

	Texas Department of Public Safety				MUST USE MOST CURRENT FORM	CONTROLLED SUBSTANCES
	Regulatory Services Division				TYPED PREFERRED OR PRINT CLEARLY	REGISTRATION
	www.dps.texas.gov				MAKE SURE ENTIRE CIRCLE IS FILLED			For DPS Use Only
					EXAMPLE: Yes  No 
	APPLICATION FOR REGISTRATION
	APPLICATION FEE $25		LATE FEE $50
	I am applying for:
	 New Registration	 Additional Registration			 Re-application
	 Renew Existing Registration			CSR			Expiration
	Must provide Registration Number			Number:			Date:		MM / DD / YYYY

APPLICANT INFORMATION (Mid-Level Practitioners: Please use Form NAR-77A-78A)

Last

First

Middle

Suffix:

Degree:

Name:

Name:

Name:

(IF ANY)

Business Name:

Social Security Number:

-

-

Email Address:

Date of Birth: mm / dd / yyyy

Current Board License Number:

Expiration Date:

MM / DD

/ YYYY

Current Federal (DEA) Registration Number (IF ANY):

Expiration Date:

MM / DD

/ YYYY

Current National Provider Identifier (NPI) (IF ANY):

Business

Address:

(Physical Address

required, if using PO box.)

City:

State:

xx

ZIP Code:

County:

Phone Number Type:

Number:

( xxx )

xxx

- xxxx

ext. xxxx

International

 Yes

 Office Cell  Home

Phone #:

 No

BUSINESS ACTIVITY (Select Only One Activity, Practitioner Specify MD, DO, DDS, DVM, DPM, OD, Etc. In The Space Provided)

 PRACTITIONER ________

 HOSPITAL

 RESEARCHER

 DISTRIBUTOR

 PHARMACY

 MANUFACTURER

 TEACHING INSTITUTION

 ANALYST/ANALITICAL LAB

DRUG SCHEDULES (Select all that apply)

 (1) SCHEDULE I, NARCOTIC

 (2) SCHEDULE II, NARCOTIC

 (3) SCHEDULE III, NARCOTIC

 (4) SCHEDULE IV

 (2N) SCHEDULE II, NON-NARCOTIC

 (3N) SCHEDULE III, NON-NARCOTIC

 (5) SCHEDULE V

LIABILITY QUESTIONS (If answer to 2, 3, or 4 is “yes” and an explanation is already on file, a new letter is not required unless information has changed.)

1. Is the applicant currently authorized to handle controlled substances under the Federal Controlled Substances Act (DEA Registration)?

 Yes  No

2. Has the applicant been convicted or placed on community supervision or other probation for a felony, a violation of Health and Safety Code,

 Yes

 No

Chapters 481-485, or another offense reasonably related to the registration sought? (If yes, attach a letter stating circumstances of such actions.)

3. Has any previous registration held by the applicant, corporation, firm, partner, officer, or stockholder of the applicant under the Texas or

 Yes

 No

Federal CSA been surrendered, revoked, denied, or is it pending such action? (If yes, attach a letter stating circumstances of such actions.)

4. If the applicant is a corporation, association, or partnership, the following must be answered. Has any officer, partner, or stockholder been

 Yes

 No

convicted of a felony, a violation of Health and Safety Code, Chapters 481-485, or another offense reasonably related to the registration

 N/A

sought? (If yes, attach a letter stating circumstances of such actions.)

FEE EXEMPTION

Does exemption of fee apply?  Yes  No

(If yes, attach Certification of Exemption From Fee, NAR-80)

I verify the information provided below is true and correct, and I understand any required fee is non-refundable. I also understand this is an official government record and any missing information and/or false statement made on this document or any other supplement provided to DPS may result in criminal prosecution.

	Date:	MM / DD / YYYY ,
Signature of Applicant (Person required to sign: Hospital-Administrator,				(Printed Name and Title)
Pharmacy- Pharmacist-in-Charge, No Stamped Signatures)

Consent to Inspect: Signature of the applicant or authorized individual further grants the director or his designee, the right to enter and to inspect the controlled premises or any records required to be kept by the Texas Controlled Substances Act.

NAR-77-78 (Rev. 09/2013)

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FORM

Note: Applicant is not required to submit Page 2 of this form.

Online Payment Instructions

Please visit www.texas.gov/DPS-CSRFee. This will not complete your renewal process, only the payment portion. Remember, if your Controlled Substances Registration expires, you have no authority to manufacture, distribute, prescribe, possess, analyze, dispense or conduct research with a controlled substance.

Application Submission

DPS cannot renew the registration until a completed renewal application has been submitted and approved. The online payment trace number must be indicated in the appropriate box on the application. Once DPS has approved your application, your renewal certificate will be mailed to the registrant’s address.

If submitting Certification of Exemption, NAR-80, include with this application.

Online Secured Email

OContact Us, select “Controlled Substances” and complete the online form

Ohttps://www.txdps.state.tx.us/rsd/contact/default.aspx

Fax to (512) 424-5799

Mailing Address: Controlled Substances Registration MSC 0438

Texas Department of Public Safety

P.O. Box 15888

Austin, Texas 78761-5888

Customer Contact: (512) 424-7293

Late Fee Notice: A $50 late fee will be charged for each renewal application received after the annual expiration date. The former registrations provides the registrant with no authority to manufacture, distribute, prescribe, possess, analyze, dispense or conduct research with a controlled substance after expiration, according to DPS Rule, section 13.29(d).

Privacy Policy

Sec. 559.003. RIGHT TO NOTICE ABOUT CERTAIN INFORMATION LAWS AND PRACTICES

(a)Each state governmental body that collects information about an individual by means of a form that the individual completes and files with the governmental body in a paper format or in an electronic format on an Internet site shall prominently state, on the paper form and prominently post on the Internet site in connection with the electronic form, that:

(1)with few exceptions, the individual is entitled on request to be informed about the information that the state governmental body collects about the individual;

(2)under Sections 552.021 and 552.023 of the Government Code, the individual is entitled to receive and review the information; and

(3)under Section 559.004 of the Government Code, the individual is entitled to have the state governmental body correct information about the individual that is incorrect.

(b)Each state governmental body that collects information about an individual by means of an Internet site or that collects information about the computer network location or identity of a user of the Internet site shall prominently post on the Internet site what information is being collected through the site about the individual or about the computer network location or identity of a user of the site, including what information is being collected by means that are not obvious.

Please visit: http://www.statutes.legis.state.tx.us/docs/GV/htm/GV.559.htm

NAR-77-78 (Rev. 09/2013)

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FORM