EFTA00521364.pdf

Completed Internet Form - NOT FOR SUBMISSION DEA/Control Number - FS5672363 Submission Date: 01-21-2019 APPLICATION FOR REGISTRATION UNDER CONTROLLED SUBSTANCES ACT OF 1970 Form DEA 224A - Completed Internet Receipt. NOT FOR SUBMISSION NAME: APPLICANT OR BUSINESS (LAST) ,SHULIAK (First, MI) KARYNA _ TAX IDENTIFYING NUMBER AND/OR SOCIAL SECURITY NUMBER XXX-XX-4619 PROPOSED BUSINESS ADDRESS. (WHEN ENTERING AM. BOX, YOU ARE REVAREO To ENTER A STREET ADDRESS) 6100 RED HOOK QTRS STE B-3 CITY ST THOMAS APPLICANTS BUSINESS PHONE NUMBER POC NAME REGISTRATION CLASSIFICATION STATE ZIP CODE VI 00802 - 1348 POC CELL PHONE NUMBER POC EMAIL 2. INDICATE 1. HERE IF YOU BUSINESS PRACTITIONER REQUIRE ACTIVITY: ORDER FORM BOOKS. 3. Drug Schedules. (Fill in all circles that apply) ,/ Schedule II ,/ Schedule II ,,, Schedule III i Schedule III V' Schedule IV ,/ Schedule V Narcotic Non Narcotic Narcotic Non Narcotic Practitioner Details National Provider ID 1063886083 * Degree IIIIIIIMIMIIIIIIIIIIIIIIIII * Birthdate MEM NM Illia * Graduation Year IIIIIMI * Professional School COLUMBIA UNIVERSITY COLLEGE OF D 4. All Applicants must answer the following: Are you currently authorized to prescribe, distribute, dispense, conduct research, or otherwise handle the controlled substances in the schedules for which you are applying under the laws of the state or jurisdiction in which you are operating or propose to operate? State License No. , . State: VI Expire Date: 09-30-2020 State Controlled Substance Lic. No. Expire Date: -- 1. Has the applicant ever been convicted of a crime in 4. If the applicant is a corporation (other than a connection with controlled substance(s) under state or corporation whose stock is owned and traded by federal law, or been excluded or directed to be excluded N the public), association, partnership, or pharmacy, from participation in a medicare or state health care has any officer, partner, stockholder or proprietor program, or any such action pending? been convicted of a crime in connection with 2. Has the applicant ever surrendered (for cause) or had controlled substance(s) under state or federal law, or ever surrendered or had a federal controlled a federal controlled substance registration revoked, N substance registration revoked, suspended, suspended, restricted or denied, or is any such action pending? restricted or denied, or ever had a state professional license or controlled substance 3. Has the applicant ever surrendered (for cause) or had registration revoked, suspended, denied. a state professional license or controlled substance N restricted, or placed on probation. or is any such registration revoked, suspended, denied. restricted. or action pending? placed on probation, or is any such action pending? N Application Complete. Internet confirmation no.: 8003622 Fee Paid: $731.00 THE DEBT COLLECTION IMPROVEMENT ACT OF 1996 (PL 104-134) REOUIRES THAT YOU FUFtNISH YOUR FEDERAL TAXPAYER IDENTIFYING NUMBER TO DEA. THIS NUMBER 6 REOUIREO FOR DEBT COLLECTION PROCEDURES SHOULD YOUR FEE BECOME UNCOLLECTABLE. IF YOU 00 NOT HAVE A FEDERAL TAXPAYER IDENTIFYING NUMBER. USE YOUR Scam. SECURITY NUMBER. 6. Payment Method: -- Card Number: Expiration Date: Fee Paid: 731.00 7. Certification for Fee Exemption EFTA00521364 Certifying Official's Name: N/A Certifying Official's Title: N/A Certifying Official's Phone: N/A Application Certification: WARNING: 21 USC 843(d), states that any person who knowingly or intentionally furnishes false or fraudulent information in the application is subject to a term of imprisonment of not more than 4 years, and a fine under Title 18 of not more than $250,000 or both. By typing my full name in the space below, I hereby certify that the foregoing information furnished on this electronic DEA application is true and correct and understand that this constitutes an electronic signature for purposes of this electronic IDEA application only. * Name of Applicant (For individual registrants, the registrant themselves MUST complete this E-Signature) or name of Officer of the Corporation/Company e-Signature: Karyna Shuliak This electronic DEA application must be certified by the applicant/registrant, if an individual; by a partner of the applicant, if a partnership; or by an officer of the applicant, if a corporation, corporate division, association, trust, or other entity. See 21 C.F.R § 1301.13(j) for more information on who can certify this application EFTA00521365 ADDITIONAL INFORMATION 1. No registration will be issued unless a completed application form has been received (21 CFR 1301.13). 2. In accordance with the Paperwork Reduction Act of 1995, no person is required to respond to a collection of information unless it displays a valid OMB control number. The OMB number for this collection is (See Above). Public reporting burden for this collection of information is estimated to average (See Above) per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information. 3. The Debt Collection Improvements Act of 1996 (31 U.S.C. §7701) requires that you furnish your Taxpayer Identification Number (TIN) or Social Security Number (SSN) on this application. This number is required for debt collection procedures if your fee is not collectible. 4. PRIVACY ACT NOTICE: Providing information other than your SSN or TIN is voluntary; however, failure to furnish it will preclude processing of the application. The authorities for collection of this information are §§302 and 303 of the Controlled Substances Act (CSA) (21 U.S.C. §§822 and 823). The principle purpose for which the information will be used is to register applicants pursuant to the CSA. The information may be disclosed to other Federal law enforcement and regulatory agencies for law enforcement and regulatory purposes, State and local law enforcement and regulatory agencies for law enforcement and regulatory purposes, and person registered under the CSA for the purpose of verifying registration. For further guidance regarding how your information may be used or disclosed, and a complete list of the routine uses of this collection, please see the DEA System of Records Notice "Controlled Substances Act Registration Records" (DEA- 005), 52 FR 47208, December 11, 1987, as modified. DIVERSION CONTROL PRIVACY POLICY EFTA00521366