New Jersey Office of the Attorney General
Division of Consumer Aairs
Drug Control Unit
124 Halsey Street, 3rd Floor, P.O. Box 45045, Newark, NJ 07101
(973) 504-6351
Controlled Dangerous Substance Registration
Reinstatement Application
Instruction sheet
Complete the reinstatement application if your C.D.S. registration has been in expired status for more than 30 days. If your C.D.S.
registration has been in expired status for fewer than 30 days, you can renew online at: https://newjersey.mylicense.com or you can call
973-273-8090 to request a paper renewal application or to get your mylicense password (to renew online).
A New Jersey C.D.S. registration is issued only for a New Jersey location. Be sure to include a check or money order, in the
correct amount, payable to the “State of New Jersey.” It will take 4-6 weeks to process this application. Your C.D.S. registration
will be mailed to the mailing address on le with your professional licensing board.
Please note:
1. A reinstatement application must be completed by any Dispenser/Prescriber/Practitioner or Mid-Level Dispenser/Prescriber/ Practitioner
whose C.D.S. registration has expired or become inactive. An active D.E.A. registration for an address which corresponds with
a New Jersey C.D.S. registration is also required. If your D.E.A. registration has expired or is inactive, contact the U.S. Drug
Enforcement Administration, 80 Mulberry Street, Newark, New Jersey 07102, (1-888-356-1071) or at www.deadiversion.usdoj.gov.
2. Reinstatement fee: If your C.D.S. registration is in an “inactive” status or it expired within the past 12 months, the Reinstatement/
Renewal fee is $40.00. If it expired more than 12 months ago, you must contact the Drug Control Unit for the correct fee amount.
3. In order to complete the attached application, please note:
a. A dispenser/prescriber/ practitioner includes medical doctors, doctors of osteopathy, dentists, optometrists, veterinarians, and
podiatrists. A mid-level dispenser/prescriber/practitioner includes physician assistants, advanced practice nurses and certied
nurse midwives. Pharmacies must complete a separate application.
b. Every person or rm handling controlled dangerous substances in New Jersey is required to have both a state and federal
registration for that purpose. Federal facilities do not require registration.
c. The address supplied must be current and an actual location where controlled dangerous substances will be stored, prescribed,
dispensed, etc. The address cannot be solely a post oce box.
d. Dentists and optometrists may only register at an address for which they hold a current registration issued by their board and at
which the C.D.S. registration is required pursuant to 3(c) above.
e. Individual practitioner applicants (medical doctors, dentists, optometrists, veterinarians, etc.) must use their own name, not
professional association/corporation or partnership information.
f. Pharmacies are required to use their common trading name (e.g. David Pharmacy), not a business or corporate name.
g. Dispensers/prescribers/practitioners must have an active and current New Jersey professional license number.
h. Optometrists may prescribe or dispense only Schedule III, IV or V controlled dangerous substances.
4. To check the status of your reinstatement application, call (973)-273-8090 and the letter code is the rst letter of your C.D.S.
registration number.
If we can be of further assistance, please call 973-504-6351 or contact us via e-mail at: askconsumera[email protected].
6/24
DDC-35
Revised 3/19
Retain a copy for your records. Mail the original and one copy with your fee to the above address.
Reinstatement Application for Registration
for Dispenser/Prescriber
Mid-Level Practitioner
Dispenser/Prescriber Identifying Data
1. New Jersey license number ______________________________________
2. Mid-Level practitioners are required to collaborate with and/or be supervised by
physicians, consistent with agreed upon parameters of their respective practices.
As concerns the prescribing and/or ordering/dispensing of C.D.S., by afxing
my signature below, I afrm that required oversight regarding C.D.S. exists
between me and a duly authorized active New Jersey physician licensee. I
understand that any C.D.S. ordering/dispensing/prescribing without the required
collaborative or supervisory oversight, or engaging in any violation of the statutes
or regulations regarding the ordering/dispensing/prescribing of C.D.S. may be
deemed professional misconduct or grounds for disciplinary sanction within the
meaning of N.J.S.A. 45:1-21.
___________________________
Applicant's signature
3. *Social Security Number: ________- _______ - _______
You disclose your Social Security number for the reasons stated below. Failure
to do so may result in a denial of licensure or certication or license or certicate
renewal.
*Pursuant to N.J.S.A. 2A:17-56.44e of the New Jersey child support enforcement law,
N.J.S.A. 54:50-25 of the New Jersey taxation law and Section 1128 E(b)(2)A of the
Social Security Act, the Unit or licensing agency to which this form is submitted is
required to obtain your Social Security number. If you do not have a Social Security
number, the Unit must ascertain the reason that you do not have one. The Unit is
further obligated to provide your Social Security number to the Director of Taxation,
the Probation Division or other agency responsible for child support enforcement
and the H.I.P. Data Bank when reporting adverse actions.
You are also being asked to consent, on a voluntary basis, to the use of your Social
Security number for the additional reasons stated below.
You are notied that under the Federal Privacy Act (5 U.S.C. Section 552a (note (b)),
the Unit or licensing agency to which this form is submitted is requesting the voluntary
disclosure of your Social Security number. If you give your consent for the use of
your Social Security number, it may be used: to verify the identity of an applicant,
to aid in the collection of nancial obligations due and owing the Unit or any other
state agency, and to aid in the disclosure to state or federal law enforcement and
licensing ofcials and agencies of information obtained in investigations pertaining
to licensure or certication and disciplinary proceedings.
I, _______________________________ ,
Consent Do Not Consent
Applicant’s signature
to the use of my Social Security number for any of the additional purposes set forth
above. I understand that my consent is voluntary and that if I do not consent, no
adverse action or inference will be taken or drawn.
Afdavit - To be executed before a notary public
County of _______________________________
I, ______________________________________ being duly sworn, depose and
say under penalty of false statement, that I am the person described and identied
in this application; that the information given in this application and all submitted
materials contain no willful misrepresentations and that the information is true and
complete. I understand that should an investigation at any time disclose otherwise,
my application may be rejected, and I may face legal sanctions if I am already
registered. I understand that in signing this application for registration, I am consenting
to any reasonable inquiry that may be necessary to verify the information that I have
provided on this form or may provide in conjunction with this application.
__________________________________
Signature of applicant
Sworn and subscribed to before me
this ______ day of _______________, 2 _____.
______________________________
Signature of notary public
Afx seal here
New Jersey Ofce of the Attorney General
Please type or print clearly.
All of the items in this section must be completed.
1.
Provide the applicant’s name and the place of business (or, if unavailable,
the New Jersey residence) to be registered (do not use solely a P.O. box).
If the
registration is for a University of Medicine and Dentistry of New Jersey
facility, include the department, room number, designation, e.g. M.E.B.,
M.S.B., etc. The address of record must be your practice location.
________________________________________________________
Last name First name MI
C.D.S. – Responsible Individual
________________________________________________________
Department Room number
________________________________________________________
Street address
______________________ New Jersey _______________________
City ZIP code
__________________________ __________________________
Home telephone number (include area code) Business telephone number (include area code)
Please note that the above-registered address is subject to inspection pursuant to N.J.S.A. 24:21-31 & 32.
2. Reinstatement fee: See instruction sheet for fees.
3. Registration requested for: Schedules II through V
If registration is being requested for only certain Schedules, please
indicate which Schedules: II III IV V
4. (a) Has any restriction been imposed which would affect your privilege
to hold a controlled dangerous substances (C.D.S.) registration for
Schedule II, III, IV or V substances in New Jersey, any other state,
the District of Columbia or in any other jurisdiction?*
Yes No
(b) Have you been arrested, indicted or convicted of a crime in
connection with controlled substances under federal law or the laws
of New Jersey, any other state, the District of Columbia or any other
jurisdiction?
Yes No
(c) Have you ever surrendered a controlled drug registration or had a
controlled drug registration revoked, suspended or denied in New
Jersey, any other state, the District of Columbia or in any other
jurisdiction?
Yes No
(d) Are there any criminal charges now pending against you in New
Jersey, any other state, the District of Columbia or in any other
jurisdiction?
Yes No
(e) Are you aware of any action now pending against your professional
license, or have you been permitted to surrender or otherwise
relinquish your professional license to avoid an inquiry or investigation
in New Jersey, any other state, the District of Columbia or in any
other jurisdiction?*
Yes No
Dispenser/Prescriber (check category)
A.P.N. (Advanced Practice Nurse)
C.N.M. (Certied Nurse Midwife)
P.A. (Physician Assistant)
C.D.S. registration number _______________________________
Federal N.J. D.E.A. number ______________________________
New Jersey Office of the Attorney General
Division of Consumer Aairs
Drug Control Unit
124 Halsey Street, 6th Floor, P.O. Box 45045
Newark, NJ 07101
(973) 504-6351
CDS Prescriber Application Attestation
I, __________________________________ and being duly sworn, depose and say under penalty of
false statement, that I am the person described and identied in this application; that I have completed
this application, which contains all information called for and bears my original signature(s); that the
information given in this application and all submitted materials contain no willful misrepresentations and
that the information is true and complete. I understand that should an investigation at any time disclose
otherwise, my application may be rejected, and I may face legal sanctions if I am already registered. I
understand that in signing this application for registration, I am consenting to any reasonable inquiry that
may be necessary to verify the information that I have provided on this form or may provide in conjunction
with this application.
______________________________________ __________________________
Signature Date
Your name
