Nj Application Registration Form – Fill Out and Use This PDF

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