34617 PDF STATE APPLICATION INDIANA CONTROLLED SUBSTANCES REGISTRATION 2025

1. Click ‘Get Form’ to open it in the editor.
2. 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.
3. 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.
4. Provide the name of your facility if applicable, along with the Indiana practice address. Remember that a P.O. Box is not acceptable here.
5. Indicate which drug schedules apply to you by checking all relevant boxes. This section is vital for compliance with state regulations.
6. If applicable, answer the questions regarding disciplinary actions or convictions truthfully and attach a signed statement if necessary.
7. Finally, sign and date the application affirmation section to confirm that all information provided is true and correct before submitting.

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