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3708-8935 (608) 261-7083 (608) 266-2112 CONTROLLED SUBSTANCES BOARD APPLICATION FOR CONTROLLED SUBSTANCES SPECIAL USE AUTHORIZATION Authorization Number Expiration date CHANGES OR CORRECTIONS: LINE OUT THE OLD, PRINT OR TYPE IN THE NEW TYPE OR PRINT CLEARLY 1. Name of Person Applying for Authorization: Credential/Title of Applicant: Institution, research lab or business facility represented by or employing applicant: Name: Address: Telephone: ( ) FAX #: ( ) Email: 2. Category of Auth.
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