Nj Application Registration Form PDF Details

Within the framework of regulatory compliance, particularly concerning controlled dangerous substances (C.D.S.), New Jersey mandates rigorous registration protocols as outlined by the New Jersey Office of the Attorney General Division of Consumer Affairs Drug Control Unit. This comprehensive requirement, detailed in an extensive instruction sheet, encapsulates the procedural essence for individuals and firms engaged in the manufacture, prescription, distribution, dispensing, and research or analysis of controlled substances within the state. Notably, the registration, which necessitates a $40 fee, is exclusive to New Jersey locales, emphasizing a clear stance on geographical specificity. Moreover, an intriguing aspect of the process is the provision for practitioners with a current D.E.A. number from another state, outlining a methodical transfer process contingent upon discontinuation of practice in said state and including perspectives on dual-state practice. Registration intricacies further elaborate on the categories of professionals involved, requirements for personal versus business or corporate names, and the criticality of an active New Jersey professional license. The form also nuances the expectation for additional information submission, should space constraints arise, hinting at the meticulous nature of the information required for a successful registration. The essence of this registration process, from its foundational legal basis to the procedural specifics and associated contingencies, underscores a comprehensive approach towards regulated control of dangerous substances within New Jersey, serving as a pivotal resource for professionals navigating this regulatory landscape.

QuestionAnswer
Form NameNj Application Registration Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesnj initial application, new jersey initial, nj application registration, registration prescriber

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New Jersey Office of the Attorney General

Division of Consumer Affairs

Drug Control Unit

124 Halsey Street, 6th Floor, P.O. Box 45045, Newark, NJ 07101

(973) 504-6351

Controlled Dangerous Substance Registration

Instruction sheet

Enclosed is a Controlled Dangerous Substance (C.D.S.) application, which you are required to submit pursuant to N.J.S.A. 24:21-1 et seq. Registration is required for every person who, or firm that, manufactures, prescribes, distributes, dispenses or conducts research or analysis utilizing controlled dangerous substances.

A New Jersey C.D.S. registration is issued only for a New Jersey location. Be sure to include a $40.00 check or money order, payable to “State of New Jersey.” It will take 4-6 weeks to process this application. Your C.D.S. registration will be mailed to the mailing address on file with your professional licensing board.

Please note:

1.If you have a current D.E.A. number in another state and plan to discontinue practice in that state, you may transfer that D.E.A. number to New Jersey by providing the following to the Drug Enforcement Administration, 80 Mulberry Street, Newark, New Jersey 07102, (888-356-1071) www.deadiversion.usdoj.gov:

a.a copy of your New Jersey professional license or a verification letter from the licensing board;

b.a copy of your New Jersey C.D.S. registration or a verification letter;

c.a copy of your out-of-state D.E.A. registration; and

d.a letter requesting an address change to the same address that is on your New Jersey C.D.S. registration.

A D.E.A. number is only valid in the state listed on the certificate.

2.If you plan to practice in both New Jersey and the state(s) where you currently hold a D.E.A. registration(s), you must also obtain a D.E.A. registration for New Jersey. Please contact the D.E.A. at the address indicated above and complete the New Jersey application.

3.In order to complete the attached application, please note:

a.A dispenser/prescriber/ practitioner includes medical doctors, doctors of osteopathy, dentists, optometrists, veterinarians, and podiatrists. A mid-level dispenser/prescriber/practitioner includes physician assistants, advanced practice nurses and certified nurse midwives. Pharmacies must complete a separate application.

b.Every person or firm handling controlled dangerous substances in New Jersey is required to have both a state and federal registration for that purpose. Federal facilities do not require registration.

c.The address supplied must be current and an actual location where controlled dangerous substances will be stored, prescribed, dispensed, etc. The address cannot be solely a post office box.

d.Dentists and optometrists may only register at the address for which they hold a current registration issued by their board and at which the C.D.S. registration is required pursuant to 3(c) above.

e.Individual practitioner applicants (medical doctors, dentists, veterinarians, etc.) must use their own name, not professional association/corporation or partnership information.

f.Pharmacies are required to use their common trading name (e.g. David Pharmacy), not a business or corporate name.

g.Dispensers/Prescribers must have an active and current New Jersey professional license number. Please write in your New Jersey professional license number in “Section B” of the application.

Advanced Practice Nurses may prescribe controlled dangerous substances, but may not purchase or maintain any stock supplies of any C.D.S. medication.

Optometrists are authorized to prescribe/dispense only Schedule III, IV and V controlled substances and must have an O.M. number registered with their board.

4.If more space is required for your response to any question on the application, please submit a separate sheet of paper identifying the section(s) to which you are responding.

If we can be of further assistance, please call 973-504-6351.

Rev. 3/19

New Jersey Office of the Attorney General

 

 

 

Initial Application for Registration

 

 

 

Drug Control Unit

 

 

 

 

 

 

 

 

 

 

 

for Dispenser – Pharmacy

 

 

 

P.O. Box 45045

 

 

 

 

 

 

 

 

 

 

New Jersey Controlled Dangerous Substances Act

 

 

 

Newark, NJ 07101

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N.J.S.A. 24:21-1 et seq.

Please type or print clearly.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section A:

All of the items in this section must be completed.

 

 

Section B:

Pharmacy Licensure Information

1. Provide the applicant’s name and the place of business to be registered (do

Pharmacy permit number _____________________________________

not use solely a P.O. box). Registration will be provided for New Jersey

locations only. If the registration is for a University of Medicine and

 

 

 

Dentistry of New Jersey facility, include the department, room number,

 

 

 

 

designation, e.g. MEB, MSB, etc. The address of record must be your

 

Section C:

Business Information

 

pharmacy/facility location.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. List the name, address and telephone number of the person who has

________________________________________________________

 

administrative or managerial responsibility for the registered location.

 

 

 

Pharmacy permit trade name

 

 

 

 

 

 

 

 

 

 

 

 

 

________________________________________________________

 

 

 

 

Last name

 

 

 

 

First name

 

 

 

 

 

 

 

 

MI

 

 

 

 

 

 

C.D.S. – Responsible Individual

 

 

 

 

 

 

 

 

 

 

 

 

 

________________________________________________________

 

 

 

 

 

Department

 

 

 

 

 

 

 

 

Room number

 

 

 

 

 

________________________________________________________

 

 

 

 

 

 

 

 

Street address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. List the name, address and telephone number of the registered agent (if a

________________________

New Jersey

__________________

 

 

corporation) or the name and address of the New Jersey resident upon whom

 

City

 

 

 

 

 

 

 

 

 

ZIP code

 

 

process may be served (if a nonresident proprietor or partner).

____________________________

__________________________

 

 

 

 

 

Home telephone number (include area code)

 

Business telephone number (include area code)

 

 

 

Note: 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 ($40)

 

 

 

 

 

 

 

 

 

 

 

 

 

Make the check or money order payable to: State of New Jersey

 

 

 

 

 

3. Registration requested in the following Schedule(s):

 

 

 

 

 

Schedule

 

 

II

 

III

 

 

IV

 

 

 

 

 

V

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section D: Certification

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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,

I, _____________________________________ being duly sworn, depose

the District of Columbia or in any other jurisdiction?*

 

 

 

 

and say under penalty of false statement, that I am the person described and

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

identified intis application; that the information given in this application and

(b) Have you been arrested, indicted or convicted of a crime in

all submitted materials contain no willful misrepresentations and that the

connection with controlled substances under federal law or the laws

of New Jersey, any other state, the District of Columbia or any other

information is true and complete. I understand that should an investigation

jurisdiction?*

 

 

 

 

 

 

 

 

Yes

No

at any time disclose otherwise, my application may be rejected, and I may

(c) Have you ever surrendered a controlled drug registration or had a

face legal sanctions if I am already registered. I understand that in signing

controlled drug registration revoked, suspended or denied in New

this application for registration, I am consenting to any reasonable inquiry

Jersey, any other state, the District of Columbia or in any other

that may be necessary to verity the information that I have provided on this

jurisdiction?*

 

 

 

 

 

 

 

 

Yes

No

form or may provide in conjunction with this application.

(d) If the applicant is a corporation, association, or partnership: has any

 

 

 

officer, partner, stockholder holding 10% or more of the outstanding shares

 

 

 

or employee who has access to controlled dangerous substances been

 

 

 

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

 

 

 

 

 

 

(e) If the applicant is a corporation, association, or partnership: has any

 

Applicant's signature

 

 

 

officer, partner, stockholder holding 10% or more of the outstanding

 

 

 

shares or employee who has access to controlled dangerous substances

____________________________________________

 

surrendered a controlled drug registration, had a controlled drug

 

registration suspended, revoked, or denied, or owned or worked

 

Date

for an entity which has surrendered or had revoked, suspended, or

 

 

 

denied a controlled drug registration under federal law or the laws

 

 

 

of New Jersey, any other state, the District of Columbia or any other

 

 

 

jurisdiction?*

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

* If "Yes," attach a letter setting forth the circumstances of such action.

For State USe only

C.D.S. number________________________ Effective date ___________________________ Expiration date ______________________

Retain the last copy for your records. Mail the remaining copies with your fee to the above address.

DDC-25 Revised 3/19

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