Ov State Form 34617 (R17 / 6-15) Approved by State Board of Accounts, 2015 * Your Social Security number is being requested by this state agency in accordance with IC 4-1-8-1. Disclosure is mandatory and this record cannot be processed without it. INSTRUCTIONS: Please type or print all information. FOR OFFICE USE ONLY CSR number Date of issuance (month, day, year) Receipt number Application fee Date fee paid (month, day, year) DO NOT WRITE ABOVE THIS LINE PRACTITIONERS (Please check on.
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How to fill out the IN 34617 online
Filling out the IN 34617 form online is essential for practitioners seeking registration for controlled substances in Indiana. This guide provides clear and detailed instructions to help you navigate the process smoothly.
Follow the steps to complete your application successfully.
- Press the ‘Get Form’ button to access the IN 34617 form and open it within your preferred online editor.
- Begin filling out your personal information. Enter your name as a practitioner, specify your profession by checking the appropriate box (e.g., Dentist, Physician, etc.), and provide your specialty.
- Input your contact details, including your telephone number and email address. Ensure that all provided information is accurate and up to date.
- Fill in the Indiana practice address with the number and street (note that a PO Box is not permitted), city, state, and ZIP code.
- Indicate the drug schedules applicable to you by checking all relevant boxes. This will help ensure the correct registration based on your practice.
- Carefully review the questions regarding compliance and past violations. Answer 'Yes' or 'No' accordingly. If you answer 'Yes' to any question, prepare a signed and notarized statement providing full details.
- Affirm the application by signing the form and entering the current date. Your signature confirms the accuracy of all the information provided.
- Once you have completed all sections, you can choose to save your changes, download the form for your records, print it, or share it as needed.
Complete your IN 34617 form online today to ensure a smooth registration process.
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