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Application for Massachusetts Controlled …

Veterinarian Application Rev. 20170119 In Accordance with the Controlled Substances Act, M.G.L. Chapter 94C Commonwealth of Massachusetts Department of Public Health, Bureau of Health Professions Licensure

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Veterinarian Application Rev. 20170119 In Accordance with the Controlled Substances Act, Chapter 94C Commonwealth of Massachusetts Department of Public Health, Bureau of Health Professions Licensure Drug Control Program 239 Causeway Street, Suite 500, Boston, MA 02114 Telephone 617-973-0949 Fax 617-753-8233 Application for Massachusetts Controlled Substances Registration for Veterinarian Please be sure to: Submit completed application form. Enclose check or money order for $ made payable to Commonwealth of Massachusetts . Enclose a copy of your current Board of Registration license. Have form signed (not initialed) and dated. Mail to the address above. The Department will make every effort to process your application as quickly as possible. Please note that processing may take 10 business days from receipt of application. Incomplete applications will be returned and will cause a delay in receiving your MCSR. For further information, visit: Application Type: (Select one) New Additional Location Recall In the boxes below, enter the requested information. 1) Degree: (Select one) DVM VMD 2) Massachusetts Board of Registration License No.: 3) DEA Controlled Substance Registration No. (If possessed): 4) Name: First: Middle: Last: Suffix: ( Jr., Sr., II, III) 5) Business Address: An application with a number and no street address cannot be processed. Out-of-state addresses require a letter of explanation. Business/ Facility Name (and Department if applicable): Street: City: State: ZIP: 6) Mailing Address: Check here if same as above Street: City: State: ZIP: 7) Business Telephone No.: ( area code ) 8) Social Security No.: (Required by c. 30A, s. 13A) 9) Drug Schedules requested: Select all that apply: II III IV V VI Schedule VI includes all prescription drugs not in Schedules II - V. Only Schedules that are checked can be authorized. 10) E-mail Address: 11) Have you ever been convicted of any violation of State or Federal law relating to the manufacture, possession, distribution or dispensing of controlled substances? Yes * No 12) Has any previous professional license or registration held by you under any name or corporate name or legal entity been surrendered, revoked, suspended or denied or is such action pending? Yes * No * If you answered Yes to Question No. 11) or No. 12), a letter must be attached setting forth circumstances of such action(s). I hereby certify that the information on this application is true to the best of my knowledge, and that I will comply with the laws of the Commonwealth of Massachusetts and all applicable rules and regulations promulgated by the Department of Public Veterinarian Application Rev. 20170119 In Accordance with the Controlled Substances Act, Chapter 94C Health. I also certify, in accordance with c. 62C, section 49A, that I have to the best of my knowledge and belief complied with all laws of the commonwealth relating to taxes, reporting of employees and contractors, and withholding and remitting of child support. Signed under the pains and penalties of perjury. Signature of applicant ________________________________________ ___________ Date _________________

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