I understand that I must comply with the provisions of the Alabama Practice Act, Rules of the Board and all other applicable statues
I affirm that all information provided herein is true and correct and I recognize that providing false information may result
in disciplinary action
Controlled Substance Waiver: I am hereby requesting the Board to issue only a license or permit and that no activities requiring a controlled substance registration will be performed during the referenced period. I understand that providing a false statement or engaging in any activity requiring a controlled substance registration may result in discipline.