Form 44049 - State Forms Online Catalog - IN 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information in the designated fields. This includes your name, date of birth, and Social Security number. Ensure accuracy as this information is mandatory for processing.
3. Select your profession by checking the appropriate box under 'PRACTITIONERS'. This helps categorize your application correctly.
4. Fill in your contact details, including telephone number and email address, to facilitate communication regarding your application.
5. Provide the Indiana practice address where you will be operating. Remember, a PO Box is not acceptable.
6. Indicate which drug schedules apply to you by checking all relevant boxes. This section is crucial for compliance with state regulations.
7. Answer the questions regarding past compliance and legal issues truthfully. If applicable, prepare a sworn affidavit detailing any affirmative responses.
8. Finally, sign and date the application affirmation at the bottom of the form to validate your submission.

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