Get In 34617 2023-2025

This guide provides comprehensive, step-by-step instructions on how to complete the Indiana Controlled Substances Registration application (IN 34617) online. By following these instructions, users can efficiently fill out the form while ensuring all necessary information is accurately provided.

Follow the steps to complete the IN 34617 application online.

1. Press the ‘Get Form’ button to access the application form and open it in your digital space.
2. Begin by entering your professional title. Choose the correct option from the categories provided (e.g., Dentist, Physician, etc.).
3. Fill in your personal information. This includes your name, Social Security number, date of birth, professional license number, and telephone number.
4. If applicable, enter the name of your facility and your email address. Ensure that the email provided is valid for correspondence.
5. Please provide your Indiana practice address. Ensure to include the full address without using a P.O. Box.
6. Indicate the drug schedules that apply to your practice by checking all relevant boxes.
7. Answer the questions provided. If any question is answered 'Yes,' prepare a signed written statement explaining the situation and include any relevant documentation.
8. Confirm whether you plan to directly dispense a controlled substance and check the corresponding box accordingly.
9. Complete the affirmation section by signing and dating the application, affirming that all statements made are true.
10. After ensuring that all fields are filled out correctly, save your changes. Users can opt to download, print, or share the completed application as necessary.

Complete your application online today and ensure a smooth submission process.