Nj Dangerous Substance Registration Form – Fill Out and Use This PDF

New Jersey Ofice 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 irmly with a ballpoint pen.

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

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

Pharmacy permit number _____________________________________

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

practice location.

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

________________________________________________________

administrative or managerial responsibility for the registered location.

Pharmacy trade name

________________________________________________________

Last name

First name

MI

C.D.S. – Responsible Individual

________________________________________________________

Department

Room number

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

________________________________________________________

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

Street address

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

________________________

New Jersey

__________________

City

ZIP code

____________________________ __________________________

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 ($20)

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

Section D:

Certiication

Schedule

II

III

IV

V

I, ______________________________________ being duly sworn,

4. (a) Has any restriction been imposed which would affect your privilege

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

to hold a controlled dangerous substances (C.D.S.) registration for

Schedule II, III, IV or V substances in New Jersey, any other state,

described and identiied in this application; that the information given

the District of Columbia or in any other jurisdiction?*

in this application and all submitted materials contain no willful

Yes

No

misrepresentations and that the information is true and complete. I

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

understand that should an investigation at any time disclose otherwise,

connection with controlled substances under federal law or the laws

my application may be rejected, and I may face legal sanctions if I

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

am already registered. I understand that in signing this application for

jurisdiction?*

Yes

No

registration, I am consenting to any reasonable inquiry that may be

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

necessary to verify the information that I have provided on this form

controlled drug registration revoked, suspended or denied in New

or may provide in conjunction with this application.

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

jurisdiction?*

Yes

No

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

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

______________________________________

or employee who has access to controlled dangerous substances been

Applicant's full signature

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

______________________________________

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

Date

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

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.

DDC-25

Revised 6/08

FOr StAte USe ONlY

C.D.S. number________________________

Effective date ___________________________ Expiration date ______________________