California Drug Take-Back Program Question Title * 1. Contact Information (1 application per facility) Facility Name Name of Person completing form Facility Address Telephone Email Hours of operation for facility DEA registration license number (not applicable to Law Enforcement) If you’re a pharmacy or hospital, or you are partnering with a authorized collector pharmacy, provide the Board of Pharmacy facility license number Question Title * 2. Will the bin be accessible to the public? Yes No Question Title * 3. Which of the following best describes where the medicine collection receptacle will be located (pick one): Pharmacy Hospital/clinic with on-site pharmacy Law enforcement Skilled nursing facility 14% of survey complete. Next