APPLICATION FOR SUBSTANCES - dps.hawaii.gov

APPLICATION Print or type registrant's name and HAWAII BUSNESS STREET ADDRESS LAW 0219 10/13 FOR controlled SUBSTANCES For State Use Only: Reg: (CHAPTER 329 HRS) Business Phone: _____ _ Cell: _____ _ NARCOTICS ENFORCEMENT DIVISION State of Hawaii Department of Public Safety 3375 Koapaka Street, #D100 Honolulu, HI 96819 Phone (808) 837-8470 Fax (808) 837-8474 Exp: Mailing Adress If Different From Above: PLEASE PRINT OR TYPE: D Check if change of address CLASSIFICATION:0 PHARMACY (NABP/NPI # _____ _D CLINIC (DRUG ROOM)D PRACTITIONER (Specify MD, DDS, DVM, etc) D LOCUM TENENS0 DISTRIBUTORD RESEARCHER - Submit ProtocolD LABORATORYD LAW ENFORCEMENTOAPRN0 LONG TERM CARE FACILITYD OTHER SCHEDULES:D SCHEDULE I (LE/Reasearchers Only)D SCHEDULE II -NarcoticD SCHEDULE II -Non-NarcoticD SCHEDULE Ill -NarcoticD SCHEDULE Ill -Non-NarcoticD SCHEDULE IVD SCHEDULE WILL BE RESTRICTED TO THE ACTIVITYCHECKED BELOW:D ADMINISTER D CERTIFY MEDICAL MARIJUANA USED PRESCRIBE D DISTRIBUTED STATE OF HAWAII LICENSE NUMBER:(Medical, Dental, Pharmacy, WALLET SIZE COPY Expiration Date DRUG ENFORCEMENT ADMINISTRATION(DEA) REGISTRATION NUMBER: (renewals only)SUBMIT LEGIBLE COPY Expiration Date Rec: D Initial YOU EMPLOYED AS A FEDERAL, STATE, OR CITY OFFICIAL?))

APPLICATION Print or type registrant's name and HAWAII BUSNESS STREET ADDRESS LAW 0219 10/13 FOR CONTROLLED SUBSTANCES For State Use Only: Reg: (CHAPTER 329 HRS) Business Phone: _____ _ Cell: _____ _ NARCOTICS

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  Substance, Controlled, Controlled substances

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