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Get NY DOH-4330 2016-2024

DOH-4330 7/12 Page 1 of 2 I II III IV V STORAGE OF CONTROLLED SUBSTANCES check all that apply Vault Describe Safe Cabinet Other Additional Security SUPERVISOR OF CONTROLLED SUBSTANCE ACTIVITY complete only if an individual other than the applicant will be supervising controlled substance activity Signature Type of Professional License and Number APPLICANT ACKNOWLEDGEMENTS The applicant fully understands that the license to be issued hereon shall be subject to the following stipulations and conditions The applicant is knowledgeable concerning all laws and regulations both State and Federal regarding the licensed activity and shall comply with such requirements. NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Narcotic Enforcement LICENSE APPLICATION to ENGAGE in a CONTROLLED SUBSTANCE ACTIVITY PLEASE PRINT OR TYPE APPLICANT INFORMATION CONTACT INFORMATION Legal Name Name d/b/a Title Street Telephone City Fax State Zip License County E-Mail If using a P. O. Box a street address must be included* APPLICATION TYPE NEW Note New applicants will be subject to an on-site facility inspection excluding out-of-state applicants. RENEWAL Note Applicants reporting a relocation and/or a change in ownership will be subject to an on-site inspection excluding out-of-state applicants. Date proposed for controlled substance activity to begin* // No Change since most recent license Name Change Address Change Postal Only Relocation Ownership Change AMENDMENT New Name New Address New Owner s Attach narrative outlining change s requested* LICENSE CLASSIFICATION check only one box Class 1 Manufacturer Class 2 Distributor Check if Reverse Distributor Class 3 Institutional Dispenser Class 4 Researcher Schedules II-V Individual Institutional Class 5 Instructional Activities Schedules II-V Class 8 Analytical Laboratory Class 9 Importer Class 10 Exporter Class 11 Pharmacy - Automated Dispensing System New License/ Renewal Fee Amendment Fee NO FEE Office Use Only Cashline Approved // Other // Comment s Reviewer New York State county and municipal agencies are exempt from licensing fees. Applicants registered with the New York State Board of Pharmacy must submit a copy of their registration* Class 1a and Class 2a applicants must attach a copy of their DEA registration* Class 3a applicants must provide their Department of Health Operating Certificate number and/or a copy of any other New York State agency license. Class 4-8 applicants must submit specific information consistent with Sections 3325 and 3326 of the Public Health Law see associated instructions. The licensee shall be under a continuing duty to inform the Department of Health of any changes such as name address or any substantial change to the physical security and means of record keeping regarding the controlled substance s. The license privilege herein applied for if granted shall not be transferred* Changes in name or ownership of institutional and business licensees shall be immediately reported to the Department of Health.

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