Get DHHS 227

FORM DHHS 227 Name of Applicant Facility Name Application for Reregistration Mailing Address under N.C. Controlled Substances Act of 1971 Location DHHS Registration No* Town DEA No* County State Zip Applicant Telephone Area Code Point of Contact Name RETAIN COPY Mail Application to Department of Health and Human Services Controller s Office-Accounts Receivable 2025 Mail Service Center Raleigh North Carolina 27699-2025 Telephone 919 733-1765 Please print or type all entries REGISTRATION CLASSIFICATION SUBMIT CHECK OR MONEY ORDER PAYABLE TO SUBSTANCE ABUSE DRUG REGULATORY 1. Business Activity Check one only A Manufacturer 600 B Distributor 500 2. Drug Schedules Check all applicable Schedule I Narcotic Non-narcotic 3. Registration as a manufacturer conveys distribution privileges only as those substances manufactured* Manufacturers Item 1A Business Activity check schedules applicable to any category in the boxes below C Researcher 125 D Analytical Laboratory 100 E Dog Handler 150 4. ALL APPLICANTS MUST ANSWER THE FOLLOWING a Are you currently authorized to manufacture distribute dispense prescribe conduct research or otherwise handle the controlled substances in the schedules for which you applying under the laws of North Carolina or the Federal Government Yes No b Has the applicant been convicted of a felony under State or Federal law relating to the manufacture possession distribution or dispensing of controlled substances I Bulk Manufacturer Synthesizer-Extractor Dosage Form Repacker-Relabeler II III IV V VI c Has any previous registration held by the applicant corporation firm partner or officer of applicant under Federal CSA or NCCSA been surrendered revoked suspended denied or is it pending such action If YES to b and/or c attach a letter setting forth the circumstances of such action* 5. Drug code numbers must coincide with the schedules requested listed below are the drug code requirements for each business activity Analytic Lab Not Required To List Drug Codes Distributor Schedule I Researcher Schedule I II III IV V and VI Manufacturer Schedule I II III IIIN IF ADDITIONAL SPACE IS REQUIRED USE A SEPARATE SHEET AND RETURN WITH APPLICATION AUTHORIZED INDIVIDUAL Date Print or Type Name Signature Official Title. Controlled Substances Act of 1971 Location DHHS Registration No* Town DEA No* County State Zip Applicant Telephone Area Code Point of Contact Name RETAIN COPY Mail Application to Department of Health and Human Services Controller s Office-Accounts Receivable 2025 Mail Service Center Raleigh North Carolina 27699-2025 Telephone 919 733-1765 Please print or type all entries REGISTRATION CLASSIFICATION SUBMIT CHECK OR MONEY ORDER PAYABLE TO SUBSTANCE ABUSE DRUG REGULATORY 1. Business Activity Check one only A Manufacturer 600 B Distributor 500 2. Drug Schedules Check all applicable Schedule I Narcotic Non-narcotic 3. Business Activity Check one only A Manufacturer 600 B Distributor 500 2. Drug Schedules Check all applicable Schedule I Narcotic Non-narcotic 3. Registration as a manufacturer conveys distribution privileges only as those substances manufactured* Manufacturers Item 1A Business Activity check schedules applicable to any category in the boxes below C Researcher 125 D Analytical Laboratory 100 E Dog Handler 150 4. .