Reinstatement Application for Registration
for Dispenser/Prescriber Practitioner
1. You must also obtain a D.E.A. registration for the same New Jersey
address of record.
2. Dentists and optometrists may only register at a New Jersey address
for which they hold a current registration issued by their board.
3. Optometrists are authorized to prescribe/dispense only Schedule III,
IV and V controlled dangerous substances.
Dispenser/Prescriber Identifying Data
*Social Security Number: ________ - _______ - ________
You disclose your Social Security number for the reasons stated below. Failure
to do so may result in a denial of licensure or certication or license or certicate
renewal.
*Pursuant to N.J.S.A. 2A:17-56.44e of the New Jersey child support enforcement law,
N.J.S.A. 54:50-25 of the New Jersey taxation law and Section 1128 E(b)(2)A of the
Social Security Act, the Unit or licensing agency to which this form is submitted is
required to obtain your Social Security number. If you do not have a Social Security
number, the Unit must ascertain the reason that you do not have one. The Unit is
further obligated to provide your Social Security number to the Director of Taxation,
the Probation Division or other agency responsible for child support enforcement
and the H.I.P. Data Bank when reporting adverse actions.
You are also being asked to consent, on a voluntary basis, to the use of your Social
Security number for the additional reasons stated below.
You are notied that under the Federal Privacy Act (5 U.S.C. Section 552a (note (b)),
the Unit or licensing agency to which this form is submitted is requesting the voluntary
disclosure of your Social Security number. If you give your consent for the use of
your Social Security number, it may be used: to verify the identity of an applicant,
to aid in the collection of nancial obligations due and owing the Unit or any other
state agency, and to aid in the disclosure to state or federal law enforcement and
licensing ofcials and agencies of information obtained in investigations pertaining
to licensure or certication and disciplinary proceedings.
I, _______________________________ ,
Consent Do Not Consent
Applicant’s signature
to the use of my Social Security number for any of the additional purposes set forth
above. I understand that my consent is voluntary and that if I do not consent, no
adverse action or inference will be taken or drawn.
Afdavit - To be executed before a notary public
County of _______________________________
I, ______________________________________ being duly sworn, depose and
say under penalty of false statement, that I am the person described and identied
in this application; that the information given in this application and all submitted
materials contain no willful misrepresentations and that the information is true and
complete. I understand that should an investigation at any time disclose otherwise,
my application may be rejected, and I may face legal sanctions if I am already
registered. I understand that in signing this application for registration, I am consenting
to any reasonable inquiry that may be necessary to verify the information that I have
provided on this form or may provide in conjunction with this application.
__________________________________
Signature of applicant
Sworn and subscribed to before me
this ______ day of _______________, 2 _____.
______________________________
Signature of notary public
DDC-34
Revised 3/19
Retain a copy for your records. Mail the original and one copy with your fee to the above address.
New Jersey Ofce of the Attorney General
Please type or print clearly.
All of the items in this section must be completed.
1.
Provide the applicant’s name and the place of business (or, if unavailable,
the New Jersey residence) to be registered (do not use solely a P.O. box).
If the regis-
tration is for a University of Medicine and Dentistry of New Jersey facility,
include the department, room number, designation, e.g. M.E.B., M.S.B.,
etc. The address of record must be your practice location.
________________________________________________________
Last name First name MI
C.D.S. – Responsible Individual
________________________________________________________
Department Room number
________________________________________________________
Street address
______________________ New Jersey ______________________
City ZIP code
__________________________ __________________________
Home telephone number (include area code) Business telephone number (include area code)
Please note that the above-registered address is subject to inspection pursuant to N.J.S.A. 24:21-31 & 32.
2. Reinstatement fee: See instruction sheet for fees.
3. Registration requested for: Schedules II through V
If registration is being requested for only certain Schedules, please
indicate which Schedules: II III IV V
4. (a) Has any restriction been imposed which would affect your privilege
to hold a controlled dangerous substances (C.D.S.) registration for
Schedule II, III, IV or V substances in New Jersey, any other state,
the District of Columbia or in any other jurisdiction?*
Yes No
(b) Have you been arrested, indicted or convicted of a crime in
connection with controlled substances under federal law or the laws
of New Jersey, any other state, the District of Columbia or any other
jurisdiction?
Yes No
(c) Have you ever surrendered a controlled drug registration or had a
controlled drug registration revoked, suspended or denied in New
Jersey, any other state, the District of Columbia or in any other
jurisdiction?
Yes No
(d) Are there any criminal charges now pending against you in New
Jersey, any other state, the District of Columbia or in any other
jurisdiction
Yes No
(e) Are you aware of any action now pending against your professional
license, or have youbeen permitted to surrender or otherwise relinquish
your professional license to avoid an inquiry or investigation in
New Jersey, any other state, the District of Columbia or in any other
jurisdiction?
Yes No
Dispenser/Prescriber (check category)
1. M.D. 4. Veterinarian
2.
D.O. 5. Podiatrist
3.
Dentist 6. Optometrist
N.J. professional license number ___________________________
C.D.S. registration number _______________________________
Federal N.J. D.E.A. number ______________________________
Afx seal here