Form DEA Form 161-r DEA Form 161-r Application for Permit to Export Controlled Substances F

OMB APPROVAL NO. 1117-0004
U.S. DEPARTMENT OF JUSTICE – DRUG ENFORCEMENT ADMINISTRATION

APPLICATION FOR PERMIT TO EXPORT CONTROLLED SUBSTANCES
FOR SUBSEQUENT REEXPORT
PURSUANT TO SECTION 1003(f), Title III, PL 109-57
(See Instructions and Privacy Act Information)
DATE:

EXPORTER APPLICATION NUMBER (If applicable)

1. NAME OF CONSIGNEE IN FIRST COUNTRY

2. ADDRESS OF CONSIGNEE IN FIRST COUNTRY

3. BUSINESS OF CONSIGNEE IN FIRST COUNTRY

4. FOREIGN PORT OF ENTRY (City & Country)

5a. PORT OF EXPORTATION (City & state of
last U.S. Customs port)

5b. NAME OF EXPORTING CARRIER OR
VESSEL (Air, Ship)

6. FOREIGN IMPORT LICENSE OR PERMIT NO.
7a. NAME AND QUANTITY OF DRUG OR
PREPARATION TO BE EXPORTED (Enter
names as shown on labels; numbers and sizes of
packages; bulk or tablets/capsules, strength of
tablets, capsules, etc, CSA Drug Code, and NDC
Number)

5c. APPROX. DATE OF EXPORTATION

ISSUE DATE:

7b. CONTROLLED SUBSTANCE CONTENT OF
DRUG OR PREPARATION TO BE EXPORTED
expressed as acid, base, or alkaloid (Enter name of
controlled substance contained in the drug, compound, or
preparation.)

EXPIRE DATE:
7c. DATE EXPORT OCCURED AND ACTUAL
QUANTITY (Completed and signed by registrant at
time of export and returned within 30 days to DEA.)
DEA PERMIT NO:
DATE ACTUALLY SHIPPED:

SIGNATURE OF RESPONSIBLE COMPANY
OFFICIAL:

8a. NAME OF CONSIGNEE IN SECOND
COUNTRY

FORM DEA 161-R

8b. ADDRESS OF CONSIGNEE IN SECOND
COUNTRY

8c. AMOUNT TO BE REEXPORTED TO SECOND
COUNTRY (Enter name of controlled substances (7b) and
net weight in gms)

OMB APPROVAL NO. 1117-0004
U.S. DEPARTMENT OF JUSTICE – DRUG ENFORCEMENT ADMINISTRATION

APPLICATION FOR PERMIT TO EXPORT CONTROLLED SUBSTANCES
FOR SUBSEQUENT REEXPORT (page 2)
9a. NAME OF CONSIGNEE IN SECOND
COUNTRY

9b. ADDRESS OF CONSIGNEE IN SECOND COUNTRY

9c. AMOUNT TO BE REEXPORTED TO
SECOND COUNTRY (Enter name of controlled
substances (7b) and net weight in gms)

10a. NAME OF CONSIGNEE IN SECOND
COUNTRY

10b. ADDRESS OF CONSIGNEE IN SECOND COUNTRY

10c. AMOUNT TO BE REEXPORTED TO
SECOND COUNTRY (Enter name of controlled
substances (7b) and net weight in gms)

11a. NAME OF CONSIGNEE IN SECOND
COUNTRY

11b. ADDRESS OF CONSIGNEE IN SECOND COUNTRY

11c. AMOUNT TO BE REEXPORTED TO
SECOND COUNTRY (Enter name of controlled
substances(7b) and net weight in gms)

PLEASE ATTACH ADDITIONAL SHEETS OF FORM DEA 161-R OR DOCUMENTATION PER TITLE 21 CFR 1312.22.

AFFIDAVIT
To the best of my knowledge and belief (1) both the first country to which the controlled substance(s) are exported from the United States and the
second country to which the controlled substances are exported are parties to the Single Convention on Narcotic Drugs, 1961, and the Convention
on Psychotropic Substances, 1971; (2) the first and second countries have each instituted and maintain a system of controls of imports in
conformity with such Conventions; (3) the drugs will be consigned to a holder of such permits or licenses as may be required in the country of
import and that a permit or license for importation will be issued for such import into the second country; (4) that the controlled substances will be
reexported from the first country to the second country no later than 90 days after exportation from the United States; (5) the packages
are labeled in conformance with the Single Convention on Narcotic Drugs, 1961 and the Convention on Psychotropic Substances, 1971, and any
amendments to these treaties; (6) the controlled substances are to be applied exclusively to medical, scientific, or other legitimate uses within the
second country; and (7) the controlled substances will not be exported from the second country.
NAME OF EXPORTER

ADDRESS OF EXPORTER

EXPORTER’S TELEPHONE NO.

EXPORTER’S DEA REGISTRATION NO.

PRINTED NAME & SIGNATURE AND TITLE OF PERSOM MAKING APPLICATION

NOTICE: Controlled Substances may not be exported by mail or parcel post.
APPROVED EXPORT PERMIT NUMBER

DEA USE ONLY

FORM DEA 161-R

DATE EXPORT PERMIT NUMBER ISSUED

INSTRUCTIONS AND INFORMATION, FORM DEA-161-R
This application must be completed in triplicate. The original is sent to DEA HQs: Drug Enforcement Administration, Office
of Diversion Control, Import/Export Unit, Washington, D.C. 20537. See Instructions 5a and 9 for copies two and three.
(1) The name and address of the consignee as shown on this application and on the permit to export must correspond
with that shown on the foreign import certificate.
(2) To avoid delays in clearance at the port of export, be sure to enter the correct port on this application. A copy of your
export permit is sent directly to the District Director of Customs at the port indicated on the application for comparison
with the permit presented for clearance of the shipment. The shipment will not clear at any other port without an
amendment of the permit indicating a change to that effect.
(3) The original or an authentic signed and/or notarized copy of the foreign import certificate must accompany this
application. If this certificate is in a foreign language, a translation must accompany the application. If this certificate is
needed to accomplish entry of the drug into the country of destination, your request for its return to you should
accompany the application.
(4) Application should be made in the name of the registered legal entity, as shown on the DEA registration certificate,
and signed by a responsible authorized official if a corporation, by a partner, or by the person registered as an
individual. Only persons registered to export may be issued export permits. The registrations of manufacturers,
distributors, practitioners, researchers, etc. do not entitle them to export controlled substances.
(5) Controlled substances in Schedule I or II, or a narcotic drug in Schedule III or IV may be exported from the United
States to a country for subsequent export from that country to another country:
a.

Thirty days from the date of exportation from the United States to the first country, the exporter must return
Copy 2 of Form DEA 161-R with 7c completed, that is, with the actual date of export and actual quantity
shipped.

b.

The controlled substances must be exported from the first country to the second country no later than 90
days from the date of exportation from the United States

c.

Within 30 days after the controlled substance is exported from the first country to the second country or the
order is canceled by the second country, the person who exported the controlled substance from the
United States must deliver to DEA Headquarters documentation certifying that such export from the first
country to the second country has occurred or was refused.
i.

The company must provide on company letterhead signed by the responsible company
official the following information: (1) Name of the second country, (2) actual quantity shipped,
(3) actual date shipped, and (4) DEA export permit number for the original export to the first
country.

ii.

For refused shipments, the company must file a written request with DEA for return, a brief
summary of the facts warranting the return, and a DEA Form 357, Application for Import
Permit. DEA will evaluate the request and return a response in writing.

(6) Permits will be mailed to the exporter at the address shown at the bottom of the application unless contrary
instructions are attached to and made a part of this application.
(7) Identification of drugs to be exported and the controlled substance content should be entered on the application in the
following manner:
8a. NAME AND QUANTITY OF DRUG OR PREPARATIONS
TO BE EXPORTED
3 bottles x 100 Secobarbital Sodium capsules (100 mg/capsule)
2 boxes x 100 Meperidine HCL ampules (5%, 2ml ampules)

8b. CONTROLLED SUBSTANCE CONTENT OF DRUG OR
PREPARATION TO BE EXPORTED (expressed as acid, base or alkaloid, not salt)
Secobarbital
24.47 gm
Meperidine
17.43 gm

1 box x 100 Meperidine HCl vials (10%, 20 ml, vials)

Meperidine

2 x 1 pt. Meperidine HCL Syrup (50 mg/5ml, pints)

Meperidine

1 box x 100 gm Dextroamphetamine Sulfate powder

Dextroamphetamine

1 bottle x 500 Hydromorphone HCl tablets (4 mg/tablets)

Hydromorphone

174.30 gm
8.24 gm
73.38 gm.
1.77 gm

(9) Copy 3 of the Application for Permit to Export Controlled Substances for Subsequent Reexport (Form DEA 161-R) is
retained by the registrant.
PRIVACY ACT INFORMATION
AUTHORITY: Section 1003 of the Controlled Substances Act of 1970 (PL-513)
PURPOSE: Control exportation of certain Controlled Substances from the United States.
ROUTINE USES: The Controlled Substances Act Registration Records produces special reports as required for statistical
analytical purposes. Disclosures of information from this system are made to the following categories of users for
the purposed states:
FORM DEA 161-R

A. Other Federal law enforcement and regulatory agencies for law enforcement and regulatory purposes.
B. State and local law enforcement and regulatory agencies for law enforcement and regulatory purposes.
C. Persons registered under the Controlled Substances Act (Public Law 91-513).
EFFECT: No permit will be issued.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a Collection of Information
unless it displays a valid OMB control number. The valid OMB control number for this Information Collection is 11170004. The time required to compete this information collection is estimated to average 15 minutes per response,
including the time to review instruction, search existing data resources, gather the data needed, and complete and
review the information collection.

FORM DEA 161-R