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34617 PDF STATE APPLICATION INDIANA CONTROLLED SUBSTANCES REGISTRATION 2026
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How to use or fill out 34617 PDF STATE APPLICATION INDIANA CONTROLLED SUBSTANCES REGISTRATION
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- Click ‘Get Form’ to open it in the editor.
- Begin by selecting your practitioner type from the options provided, such as Dentist, Physician, or Veterinarian. This will guide the subsequent fields you need to complete.
- Fill in your personal details including your name, professional license number, telephone number, and date of birth. Ensure accuracy as this information is crucial for processing your application.
- Provide the name of your facility if applicable, along with the Indiana practice address. Remember that a P.O. Box is not acceptable here.
- Indicate which drug schedules apply to you by checking all relevant boxes. This section is vital for compliance with state regulations.
- If applicable, answer the questions regarding disciplinary actions or convictions truthfully and attach a signed statement if necessary.
- Finally, sign and date the application affirmation section to confirm that all information provided is true and correct before submitting.
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Related links
Nov 22, 1997 Public Meeting held November 6, 1997 State Registration Board for Professional Engineers, Land Surveyors and Geologists; Examination Fees;
State Form 34617 (R23. The fee for this application is $60.00, payable to the Indiana Professional Licensing Agency,