ON-LINE REGISTRATION CONSISTS OF SIX (6) SECTIONS. Please have the following information available before you begin the application:
Section 1. Personal/Business Information
If you are applying for an Individual Registration (Practitioner, MLP, Researcher) you are required to provide your Full Name, Address, Social Security Number, and Phone Number. If you are applying for a Business Registration, you are required to provide the Name of the Business, Address, Tax ID, and Phone Number.
Section 2. Activity
Business Activity and Drug Schedule information. In addition - Certain registrants for forms 225 and 510 will need to provide specific drug codes and/or chemical codes related to their operations.
Section 3. State License(s)
It is mandatory to provide State medical and/or controlled substance licenses/registrations. For mid-level practitioners, this includes supervisory agreements, with specific authority for controlled substances, if required by your state. Failure to provide VALID and ACTIVE state licenses will be cause to declare the application as defective and it will be withdrawn WITHOUT refund.
Section 4. Background Information Information pertaining to controlled substances in the applicant's background.
Section 5. Payment
Payment, via this on-line application, must be made with a Visa or MasterCard, American Express, or Discover. Application fees are not refundable.
Section 6. Confirmation
Applicants will confirm the entered information, make corrections if needed, and electronically submit the application and a submission confirmation will be presented. Applicants will be able to print copies for their records.
WARNING: 21 USC 843(d), states that any person who knowingly or intentionally furnishes false or fraudulent information in the application is subject to a term of imprisonment of not more than 4 years, and a fine under Title 18 of not more than $250,000, or both.