New Mexico Board of Pharmacy 5200 OAKLAND NE SUITE A Albuquerque, NM 87113 Phone (505)222-9830 In-State Toll Free (800) 565-9102 **RENEW ONLINE** www.rld.state.nm.us/pharmacy Sarah.Trujillo@state.nm.us FACILITY CONTROLLED SUBSTANCE REGISTRATION APPLICATION Applications and fees must accompany each; otherwise processing time will be delayed. Retain a copy of both the application and form of payment for future reference. Mail early-5-10 days processing time once application is received Mailing Address: _______________________________ _______________________________ _______________________________ Fax Number: ______________ Email: __________________ Location Address: _________________________________ _________________________________ _________________________________ Phone Number: _______________ Web Address: _________________ *[ ] NEW (please see back of form for fees) SCHEDULE OF DRUGS (circle): 2 Circle type of facility: Pharmacy Hospital Clinic 2N 3 Wholesale 3N 4 Distributor 5 Repacker Manufacturer/Repacker New Mexico Board of Pharmacy Facility License #______________________ DEA #______________________ Expiration date ______________ List all trade or business names ("DBA" names) previously or currently used by same corporation or by licensee: _____________________________________________________ I/We have not been arrested, investigated for, charged with, convicted of, sentenced, entered a plea of nolo contendere, or entered into any other legal agreements for any criminal offense in any state, territory or possession of the United States or by the federal government. Signature________________________________________________ I/We have not any disciplinary actions, or have any pending actions against me, or to my knowledge been investigated by any professional licensing authority. Signature________________________________________________ *Please explain any failure to sign the statements above. Explain the circumstances, include a copy of the judgment, and attach to this application. I/We hereby certify that the information given in this application is true and correct to the best of my knowledge. Date of Birth: / / Signature Date____________________________ Print Name and Title___________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com FEE SCHEDULE FOR NEW REGISTRANTS ONLY Enclosed is the controlled substance application you requested. Only the initial year of licensure is prorated. New Mexico charges $5.00 per month for this registration. Your controlled substance number will expire in the same month as your DEA number. The first letter of your last name or the first letter of your business name determines the month in which your DEA number will expire. Therefore, please submit only the amount of money required from the current month through your expiration month. The chart shows when your DEA number will expire: January – M February – S March – L & P April – Q & R May – U, V, W, X, Y, Z June – A & D July – B August – C & E September – F & G October – H & N November – I & T December – J, K & O Licenses must be acquired in the following order: 1st : Professional License 2nd: NMCS Registration 3rd: DEA Registration 9-07 American LegalNet, Inc. www.FormsWorkFlow.com