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DPS Controlled Substance License Application and Instructions

DPS Form hints: Apply after receiving your DEA number. The DPS application must be completed on paper. Fax copies are not accepted, it must be snail mailed. According to Peter Allen at the Texas Department of Safety: o Applicant signature must be in BLUE INK. o Write "NEW" in the left margin of the application Allow 2-3 weeks for a reply after mailing. Mail to: Controlled Substances Registration Texas Department of Public Safety PO Box 15999 Austin, TX 78761-5999

Questions ­ Jody Patterson or Peter Allen 512.424.7565 in Controlled Substances Registration

Page 1 of 1 PAM Program 07.05.12

TEXAS DEPARTMENT

OF

PUBLIC SAFETY

5805 N LAMAR BLVD * PO BOX 4087 * AUSTIN TX 78773.0438 512.424.2188 www.txdps.state.tx.us

Dear Applicant: Enclosed is an application for registration in compliance with the Texas Controlled Substances Act which must be completed for a location in Texas if you prescribe, administer, dispense, research, manufacture, distribute, or analyze controlled substances. Location address must include a street address. This office will not accept a post office box only. The DPS Drug Rules are available at: http://info.sos.state.tx.us/pls/pub/readtac$ext.ViewTAC?tac_view=4&ti=37&pt=1&ch=13

The application must be completed in detail and the forwarded to this office, along with a registration fee of $25.00 made payable to the Texas Department of Public Safety, unless exempt from payment of fee. A photocopy of the application will not be accepted. Special attention must be given to Item "E" as each question must be answered. A copy of the application for registration should be retained for your files. If registering as a practitioner, hospital or pharmacy, please register for Schedules II through V controlled substances. A license from your respective licensing board must be obtained prior to registration by this Department. Your application will be returned to you if you do not hold a current license with your respective licensing board. Disregard Item "D" as you must obtain this certificate before registering with the Drug Enforcement Administration unless a DEA certificate has been previously issued. Information for ordering Schedule II prescription forms will be mailed to practitioners under separate cover after issuance of a DPS registration. If registering as a researcher, manufacturer, distributor, teaching institution or analyst, you must be registered with the Drug Enforcement Administration prior to registration with this Department. Submission of a photocopy of the DEA certificate with the application and fee will expedite issuance of the DPS Registration Certificate. If registering as a researcher for Schedule I, you must submit a copy of your research protocol. Please return application to: Controlled Substances Registration, Texas Department of Public Safety, PO Box 15999, Austin, Texas, 78761-5999 Sincerely,

Jody Patterson, Supervisor Controlled Substances Registration Regulatory Programs Narcotics Service Texas Department of Public Safety JP:

COURTESY * SERVICE * PROTECTION

APPLICATION FOR REGISTRATION Texas Controlled Substances Act, Chapter 481 of the Health and Safety Code

$25.00 FEE ­ Only Original Application Accepted

(No Photocopies)

For Department of Public Safety Use Only

APPLICANT'S NAME (Last, First, Middle; if an individual)

BUSINESS STREETADDRESS (PO BOX ONLY WILLNOTBE ACCEPTED)

CITY

STATE

ZIP

COUNTY

/

/ one only)

B

APPLICANT'S DATE OF BIRTH

DRUG SCHEDULES (Check þ All Applicable)

C

CURRENT TX BOARD LICENSE NO.

A

BUSINESS ACTIVITY (Check þ

o (1) SCHEDULE I o (2) SCHEDULE II, NARCOTIC o (2N) SCHEDULE II, NONNARCOTIC o (3) SCHEDULE III, NARCOTIC o (3N) SCHEDULE III, NONNARCOTIC o (4) SCHEDULE IV o (5) SCHEDULE V

Submit separate application and fee for each business activity. If practitioner, specify MD, DO, DDS, DVM, DPM, OD, etc., in space provided. o 1. PRACTITIONER __________ o 2. PHARMACY o 3. HOSPITAL o 4. MANUFACTURER o o o o 5. R E S E A R C H E R 6. TEACHING INSTITUTION 7. DISTRIBUTOR 8. ANALYST/ANALYTICALLAB

D

CURRENT FEDERAL(DEA) REGISTRATION NO. IF ANY

Questions and Authorizing Signature

Provisions applicable only to a claim of governmental exemption.

E

ALLAPPLICANTS MUST ANSWER THE FOLLOWING:

G

NO

CERTIFICATION OF EXEMPTION FROM FEE

1. Is applicant currently authorized to handle controlled substances under the laws of the Federal Controlled Substances Act (DEARegistration)? 2. Has the applicant been convicted of or placed on community supervision or other probation for a felony, a violation of Health and Safety Code, Chapters 481-485, or another offense reasonably related to the registration sought or is it pending such action? 3. Has any previous registration held by the applicant, corporation, firm, partner, officer or stockholder of the applicant under the Texas or Federal CSAbeen surrendered, revoked, denied or is it pending such action? 4. IF THE APPLICANT IS A CORPORATION, ASSOCIATION OR PARTNERSHIP, THE FOLLOWING MUST BE ANSWERED. Has any officer, partner or stockholder been convicted of a felony, a violation of Health and Safety Code,Chapters 481-485, or another offense reasonably related to the registration sought?

o

YES

o

ONLY AN OFFICER, EMPLOYEE, OR AGENT OF, OR A UNIT OF FEDERAL, STATE, OR LOCAL GOVERNMENT IS EXEMPT FROM PAYMENT OF REGISTRATION FEE. ADDRESS MUSTCLEARLY REFLECTTHE GOVERNMENTALOR STATE AGENCYBYWHICH AN APPLICANT IS EMPLOYED. EXEMPTION AUTHORIZES APPLICANT TO HANDLE CONTROLLED SUBSTANCES AT EXEMPTLOCATION ONLY. 1. Name of governmental unit by whom applicant is employed. (e.g., U.S. Public Health Service, University of Texas, Harris County Hospital, Dallas City Health Clinic, etc.)

o

YES

o

NO

o

YES

o

NO

2. Is the person whose signature appears in Item F authorized to administer, dispense or obtain controlled substances from official stock; or to conduct research, instructional activity or chemical analysis with controlled substances? 3. Is the person authorized to purchase controlled substances?

o o

YES YES

o o

NO NO

o

YES

o

NO

Signature and Official Title of applicant's certifying superior

If answer to a question is YES to 2, 3, or 4, attach a letter setting forth the circumstances of such action.

Printed name of certifying superior

F

SIGN AND DATE HERE

Date Signed Timely Action By DPS: (1) The director shall approve or deny a completed application within 60 days of receipt. (2) The director shall notify an applicant in writing within 60 days of receipt of an application that: (a) the application is complete and accepted for filing; or (b) the application is deficient or incomplete. STATE GOVERNMENT PRIVACYPOLICY Sec. 559.003. RIGHT TO NOTICE ABOUTCERTAIN INFORMATION LAWS AND PRACTICES. 1) with few exceptions, an individual is entitled to be informed about information that a state governmental body collects about an individual; 2) an individual is entitled to receive and review the information, and 3) an individual is entitled to have the state governmental body correct information about the individual that is incorrect.

SIGNATURE OF APPLICANT OR AUTHORIZED INDIVIDUAL Date Signed (Must be signed by Administrator, if Hospital or Pharmacist-in-Charge, if Pharmacy) NO STAMPED SIGNATURES. Please sign in Blue Ink.

( TITLE (If the applicant is a corporation, institution, or other entity, enter the TITLE of the person signing on behalf of the applicant, e.g., President, Dean, Pharmacist-in-Charge, Procurement Officer, etc.)

)

APPLICANT'S BUSINESS TELEPHONE NUMBER

NOTICE: Signature of 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.

The $25.00 registration fee must be a personal, business, certified or cashier's check, or money order made payable to: "Texas Department of Public Safety."

MAIL TO:

Controlled Substances Registration MSC 0438 Texas Department of Public Safety P O Box 15999 Austin, Texas 78761-5999 TELEPHONE (512) 424-2188

NAR-77(e) (Rev. 09/05) E-mail App.

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