Facility Controlled Substance Registraion Application

New Mexico Regulation and Licensing Department BOARDS AND COMMISSIONS DIVISION Board of Pharmacy 5 20 0 Oak l a n d Av e n u e, N E Su it e A Al b u q u er q u e, N e w Mex i c o 8 711 3 (5 0 5 ) 2 2 2 -9 8 3 0 Fax ( 50 5 ) 2 2 2 -9 8 4 5 ( 8 0 0 ) 5 65 - 91 0 2 ht t p: / / ww w. r l d. st at e. n m. u s / b oar d s / p har m ac y. a s px FACILITY CONTROLLED SUBSTANCE APPLICATION Mail early processing time is 5 to 10 business days once we receive your application. Name & Mailing Address Location Address: (If different than mailing) ____________________________________ ____________________________________ ____________________________________ Telephone Number: ___________________________ ___________________________________ ___________________________________ ___________________________________ Fax Number: _______________________________ Schedule of Drugs ( all needed): Check type of facility: Pharmacy Hospital Teaching Institute 2 2N 3 3N 4 5 Researcher Manufacturer/Repacker Clinic Wholesale Distributor Analytical Lab Repacker NM Board of Pharmacy License Number (If already have): _____________________________ DEA # (If already have) ______________________ Expiration date _____________________ I/we have not since the time of our initial licensure or last renewal, been arrested, investigated for, charged with, convicted of, sentenced, entered a plea of nolo contendere, or entered into any other legal agreements for any criminal offense in any state, territory or possession of the United States or by the federal government.* Signature__________________________________________________________________ I/we have not since the time of our initial licensure or last renewal, had any disciplinary actions, or has any professional licensing authority investigated any pending actions against us/me, or to my knowledge.* Signature__________________________________________________________________ *Please explain any affirmative answer to questions above. Explain the circumstances, include a copy of the judgment, and attach to this application. I hereby certify that the information given in this application is true and correct to the best of my knowledge. Signature _____________________ Date____________________________ Print Name and Title_________________________________________________________________________ Application and fees must accompany each other; otherwise application process will be delayed. FEE SCHEDULE FOR NEW REGISTRANTS ONLY The chart shows when your controlled substance number will expire. New Mexico charges $5.00 per month for this registration since the first year is prorated. The first letter of your business name determines the month in which your license number will expire; please submit only the amount of money required from the current month through the month that appears below next to the first letter of your business name. January - M February - S March ­ L, P April ­ Q, R May ­ U, V, W, X, Y, Z June ­ A, D July - B August ­ C, E September ­ F, G October ­ H, N November ­ I, T December ­ J, K, O Mail check or money order payable to New Mexico Board of pharmacy to the address above RETAIN A COPY OF BOTH THE APPLICATION AND FORM OF PAYMENT FOR FUTURE REFERENCE. Revision date: 02/2012 American LegalNet, Inc. www.FormsWorkFlow.com