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Get In 34617 2023-2025

Reset Form PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, IN 46204 www.pla.IN.gov APPLICATION FOR INDIANA CONTROLLED SUBSTANCES REGISTRATION (CSR) FOR PRACTITIONERS State Form 34617 (R22 / 6-23) INSTRUCTIONS: 1. The fee for this application is $60.00, payable to the Indiana Professional Licensing Agency, in accordance with 856 IAC 2-3-9(f). 2. Completed application and fees should be mailed to the address listed in the upper right hand corner of this form.

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