Get 34617.pdf. State Application Indiana Controlled Substances Registration

Filling out the 34617.PDF form is an essential step for practitioners and non-practitioners seeking to register for an Indiana controlled substances license. This guide will provide you with clear, step-by-step instructions to ensure that you complete the application accurately and efficiently.

Follow the steps to complete your application successfully.

1. Click ‘Get Form’ button to obtain the 34617.PDF and open it for editing.
2. Carefully review the 'For official use only' section at the top of the form for any relevant instructions. Fill in the CSR No. and Receipt No. only if applicable.
3. Indicate your practitioner type by checking the appropriate box, such as Dentist, Physician, or Veterinarian, depending on your professional role.
4. Enter your name, professional license number, telephone number, and date of birth in the designated fields.
5. If associated with a facility, fill in the 'Name of Facility' field and provide the full Indiana practice address, including city, state, and zip code.
6. Check all applicable drug schedules that apply to your practice. You can select multiple options if relevant.
7. Answer the questions regarding disciplinary actions and convictions truthfully. If applicable, provide a signed and notarized statement detailing the issues. Avoid using letters from attorneys or insurance companies, as these will not be accepted.
8. Sign and date the application affirmation at the bottom of the form, swearing the information provided is true and correct.
9. For non-practitioners, check the appropriate box for your type of organization, and fill in the corresponding details for the facility, including the person responsible for controlled substances.
10. Once all sections are filled, review your application for any errors or omissions. After ensuring everything is accurate, save the changes, download the form, print a copy, or share as needed.

Complete your 34617.PDF form and submit your controlled substances registration application online today.