Free 34617.FH11 - Indiana

APPLICATION FOR INDIANA CONTROLLED SUBSTANCES REGISTRATION (CSR) FOR PRACTITIONERS
State Form 34617 (R14 / 6-07) Approved by State Board of Accounts, 2007

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PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 www.pla.IN.gov

* Your Social Security number is being requested by this state agency in accordance with IC 4-1-8-1. Disclosure is mandatory and this record cannot be processed without it.

INSTRUCTIONS:

Please type or print all information. FOR OFFICE USE ONLY

CSR number Receipt number Application fee

Date of issuance (month, day, year) Date fee paid (month, day, year)

DO NOT WRITE ABOVE THIS LINE
PRACTITIONERS
(Please check one box) Dentist Name of practitioner T elephone number Professional license number Physician Osteopathic Physician Podiatrist Veterinarian Specialty Date of birth (month, day year) E-mail address Social Security number * Advanced Practice Nurse Physician Assistant

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Name of Facility (if applicable) Indiana practice address (number and street [may not be a PO Box], city, state, and ZIP code) Drug schedules: (Check all applicable) 1 2 2 Narcotic 3

3 Narcotic

4

5

If your answer is Yes to any of the following, explain fully in a signed and notarized statement, including all related details. Include the violation, location, date and disposition. Letters from attorneys or insurance companies are not accepted in lieu of your statement. Falsification of any of the following is grounds for permanent revocation of a registration issued pursuant to this application. 1. Have you ever been convicted of, or plead guilty or nolo contendere to: a violation of any federal, state, or local law relating to the use, manufacturing, distribution, or dispensing of controlled substances or are formal charges pending? 2. Have you ever been convicted of, or plead guilty or nolo contendere to: any offense, misdemeanor, or felony, in any state (except minor traffic laws/fines) or are formal charges pending? 3. Have you ever had any action, discipline or revocation on your DEA (US Drug Enforcement Administration) registration or entered into a Memorandum of Understanding (MOU) on said registration? Yes Yes Yes No No No

APPLICATION AFFIRMATION I hereby swear or affirm under the penalties of perjury, that the statements made in this application are true, complete and correct.
Signature of practitioner Date (month, day, year)