DEA-224A Application for Registration Renewal

Under the Controlled Substances Act

INSTRUCTIONS

Save time - renew on-line at www.deadiversion.usdoj.gov
1. To renew by mail complete this application. Keep a copy for your records.
2. Mail this form to the address provided in Section 6 or use enclosed envelope.
3. The "MAIL-TO ADDRESS" can be different than your "PLACE OF BUSINESS" address.
4. If you have any questions call 800-882-9539 prior to submitting your application.
IMPORTANT: DO NOT SEND THIS APPLICATION AND RENEW ON-LINE.

MAIL-TO ADDRESS

SECTION 1

APPROVED OMB NO 1117-0014
FORM DEA-224A (09-11)
FORM EXPIRES: 11/30/2011

RENEWAL APPLICATION FOR REGISTRATION

Form-224A
Renewal

REGISTRATION INFORMATION:
DEA #
REGISTRATION EXPIRES
FEE IS NON-REFUNDABLE

Please print mailing address changes to the right of the address in this box.

UPDATE REGISTRATION INFORMATION - Please fill in missing information and make corrections if needed to any data we have on record for your registration.

Name 1 :

Name 2 :

PLACE OF
BUSINESS

Street
Address
Line 1 :

PLACE OF
BUSINESS

Address
Line 2 :
City
State :
Zip

Business
Phone
Number :

Business
Fax
Number :

Point of
Contact :

EMAIL
Address :

DEBT COLLECTION
INFORMATION

Social Security Number (if registration is for individual)

Mandatory pursuant
to Debt Collection
Improvements Act

FOR
Practitioner
or
MLP
ONLY:

Tax Identification Number (if registration is for business)

Provide SSN or TIN.
See additional information
note #3 on page 4.

Professional
Degree :
select from
list only

Professional
School :

Year of
Graduation :

National Provider Identification:

Date of Birth (MM-DD-YYYY):
M M

SECTION 2
DRUG SCHEDULES

Check this box if you wish to register for the same schedule(s):

D D

Y

Y Y

Y

Check this box if you require official order forms:
For purchase of schedule 2 controlled substances

NO CHANGE
-OR
CHANGE

If you want to make a change, check all the schedules that you are requesting for this registration:
Schedule 2 Narcotic

Schedule 3 Narcotic

Schedule 4

Schedule 2 Non-Narcotic (2N)

Schedule 3 Non-Narcotic (3N)

Schedule 5

224A RENEWAL - Page 1

SECTION 4
STATE LICENSE(S)
MANDATORY

You MUST be 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.
Expiration
Date

TEM/Salud Numero

Expiration
Date

ASSMCA Numero

Expiration
Date

Colegio de Medicos Numero

SECTION 5
LIABILITY

/
/
/

/

MM - DD - YYYY

Date(s) of incident MM-DD-YYYY:

All questions in
this section must
be answered.

/

MM - DD - YYYY

1. Has the applicant ever been convicted of a crime in connection with controlled substance(s) under state or federal law,
or been excluded or directed to be excluded from participation in a medicare or state health care program, or is any such
action pending?

IMPORTANT

/

MM - DD - YYYY

YES

NO

YES

NO

YES

NO

YES

NO

2. Has the applicant ever surrendered (for cause) or had a federal controlled substance registration revoked, suspended,
restricted, or denied, or is any such action pending?
Date(s) of incident MM-DD-YYYY:
3. Has the applicant ever surrendered (for cause) or had a state professional license or controlled substance registration
revoked, suspended, denied, restricted, or placed on probation, or is any such action pending?
Date(s) of incident MM-DD-YYYY:
4. If the applicant is a corporation (other than a corporation whose stock is owned and traded by the public), association,
partnership, or pharmacy, has any officer, partner, stockholder, or proprietor been convicted of a crime in connection with
controlled substance(s) under state or federal law, or ever surrendered, for cause, or had a federal controlled substance
registration revoked, suspended, restricted, denied, or ever had a state professional license or controlled substance
registration revoked, suspended, denied, restricted or placed on probation, or is any such action pending?
Date(s) of incident MM-DD-YYYY:

EXPLANATION OF
"YES" ANSWERS

Liability question #

Note: If question 4 does not apply to you, be sure to mark 'NO'.
It will slow down processing of your application if you leave it blank.
Location(s) of incident:

Applicants who have
answered "YES" to
Nature of incident:
any of the four questions
above must provide
a statement to explain
each "YES" answer.

Use this space or attach
a separate sheet and
Disposition of incident:
return with application

SECTION 6

EXEMPTION FROM APPLICATION FEE
Check this box if the applicant is a federal, state, or local government official or institution. Does not apply to contractor-operated institutions.

Business or Facility Name of Fee Exempt Institution. Be sure to enter the address of this exempt institution in Section 1.

The undersigned hereby certifies that the applicant named hereon is a federal, state or local government official or institution,
and is exempt from payment of the application fee.
FEE EXEMPT
CERTIFIER
Provide the name and
phone number of the
certifying official

SECTION 7
METHOD OF
PAYMENT

Signature of certifying official (other than applicant)

Date

Print or type name and title of certifying official

Telephone No. (required for verification)

Check

Make check payable to: Drug Enforcement Administration
See page 4 of instructions for important information.

American Express

Check one form of
payment only

Credit Card Number

Sign if paying by
credit card

Signature of Card Holder

Discover

Master Card

Mail this form with payment to:

Visa

DEA Headquarters
ATTN: Registration Section/ODR
P.O. Box 2639
Springfield, VA 22152-2639

Expiration Date

FEE IS NON-REFUNDABLE

Printed Name of Card Holder

SECTION 8
APPLICANT'S
SIGNATURE
Sign in ink

I certify that the foregoing information furnished on this application is true and correct.
Signature of applicant (sign in ink)

Date

Print or type name and title of applicant
WARNING: 21 USC 843(d), states that any person who knowingly or intentionally furnishes false or fraudulent information in the application
NEW - Page 2
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.

SECTION 4

You MUST be 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(S)

Expiration
Date

State License Number

MANDATORY
Be sure to include both
state license numbers

What state was this license issued in?
State Controlled Substance
License Number

Expiration
Date
What state was this license issued in?

SECTION 5
LIABILITY

/

/

All questions in
this section must
be answered.

1. Has the applicant ever been convicted of a crime in connection with controlled substance(s) under state or federal law,
or been excluded or directed to be excluded from participation in a medicare or state health care program,or is any such
action pending?
2. Has the applicant ever surrendered (for cause) or had a federal controlled substance registration revoked, suspended,
restricted, or denied, or is any such action pending?
Date(s) of incident MM-DD-YYYY:
3. Has the applicant ever surrendered (for cause) or had a state professional license or controlled substance registration
revoked, suspended, denied, restricted, or placed on probation, or is any such action pending?
Date(s) of incident MM-DD-YYYY:
4. If the applicant is a corporation (other than a corporation whose stock is owned and traded by the public), association,
partnership, or pharmacy, has any officer, partner, stockholder, or proprietor been convicted of a crime in connection with
controlled substance(s) under state or federal law, or ever surrendered, for cause, or had a federal controlled substance
registration revoked, suspended, restricted, denied, or ever had a state professional license or controlled substance
registration revoked, suspended, denied, restricted or placed on probation, or is any such action pending?
Date(s) of incident MM-DD-YYYY:

EXPLANATION OF
"YES" ANSWERS

Liability question #

/

MM - DD - YYYY

Date(s) of incident MM-DD-YYYY:

IMPORTANT

/

MM - DD - YYYY

YES

NO

YES

NO

YES

NO

YES

NO

Note: If question 4 does not apply to you, be sure to mark 'NO'.
It will slow down processing of your application if you leave it blank.
Location(s) of incident:

Applicants who have
answered "YES" to
Nature of incident:
any of the four questions
above must provide
a statement to explain
each "YES" answer.
Use this space or attach
a separate sheet and
Disposition of incident:
return with application

SECTION 6

EXEMPTION FROM APPLICATION FEE
Check this box if the applicant is a federal, state, or local government official or institution. Does not apply to contractor-operated institutions.

Business or Facility Name of Fee Exempt Institution. Be sure to enter the address of this exempt institution in Section 1.

The undersigned hereby certifies that the applicant named hereon is a federal, state or local government official or institution,
and is exempt from payment of the application fee.
FEE EXEMPT
CERTIFIER
Provide the name and
phone number of the
certifying official

SECTION 7
METHOD OF
PAYMENT

Signature of certifying official (other than applicant)

Date

Print or type name and title of certifying official

Telephone No. (required for verification)

Check

Make check payable to: Drug Enforcement Administration
See page 4 of instructions for important information.

American Express

Check one form of
payment only

Credit Card Number

Sign if paying by
credit card

Signature of Card Holder

Discover

Master Card

Mail this form with payment to:

Visa

DEA Headquarter
ATTN: Registration Section/ODR
P.O. Box 2639
Springfield, VA 22152-2639

Expiration Date

FEE IS NON-REFUNDABLE

Printed Name of Card Holder

SECTION 8
APPLICANT'S
SIGNATURE
Sign in ink

I certify that the foregoing information furnished on this application is true and correct.
Signature of applicant (sign in ink)

Date

Print or type name and title of applicant
WARNING: 21 USC 843(d), states that any person who knowingly or intentionally furnishes false or fraudulent information in the application
NEW - Page 2
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.

SECTION 4

You MUST be 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

State License Number

MANDATORY

What state was this license issued in?

Expiration Date

SECTION 5
LIABILITY

/

/

MM - DD - YYYY

1. Has the applicant ever been convicted of a crime in connection with controlled substance(s) under state or federal law,
or been excluded or directed to be excluded from participation in a medicare or state health care program,or is any such
action pending?
Date(s) of incident MM-DD-YYYY:

IMPORTANT

2. Has the applicant ever surrendered (for cause) or had a federal controlled substance registration revoked, suspended,
restricted, or denied, or is any such action pending?

All questions in
this section must
be answered.

Date(s) of incident MM-DD-YYYY:
3. Has the applicant ever surrendered (for cause) or had a state professional license or controlled substance registration
revoked, suspended, denied, restricted, or placed on probation, or is any such action pending?
Date(s) of incident MM-DD-YYYY:
4. If the applicant is a corporation (other than a corporation whose stock is owned and traded by the public), association,
partnership, or pharmacy, has any officer, partner, stockholder, or proprietor been convicted of a crime in connection with
controlled substance(s) under state or federal law, or ever surrendered, for cause, or had a federal controlled substance
registration revoked, suspended, restricted, denied, or ever had a state professional license or controlled substance
registration revoked, suspended, denied, restricted or placed on probation, or is any such action pending?
Date(s) of incident MM-DD-YYYY:

EXPLANATION OF
"YES" ANSWERS

Liability question #

NO

YES

NO

YES

NO

YES

NO

Note: If question 4 does not apply to you, be sure to mark 'NO'.
It will slow down processing of your application if you leave it blank.
Location(s) of incident:

Applicants who have
answered "YES" to
Nature of incident:
any of the four questions
above must provide
a statement to explain
each "YES" answer.
Use this space or attach
a separate sheet and
Disposition of incident:
return with application

SECTION 6

YES

EXEMPTION FROM APPLICATION FEE
Check this box if the applicant is a federal, state, or local government official or institution. Does not apply to contractor-operated institutions.

Business or Facility Name of Fee Exempt Institution. Be sure to enter the address of this exempt institution in Section 1.

The undersigned hereby certifies that the applicant named hereon is a federal, state or local government official or institution,
and is exempt from payment of the application fee.
FEE EXEMPT
CERTIFIER
Provide the name and
phone number of the
certifying official

SECTION 7
METHOD OF
PAYMENT

Signature of certifying official (other than applicant)

Date

Print or type name and title of certifying official

Telephone No. (required for verification)

Check

Make check payable to: Drug Enforcement Administration
See page 4 of instructions for important information.

American Express

Check one form of
payment only

Credit Card Number

Sign if paying by
credit card

Signature of Card Holder

Discover

Master Card

Mail this form with payment to:

Visa

DEA Headquarter
ATTN: Registration Section/ODR
P.O. Box 2639
Springfield, VA 22152-2639

Expiration Date

FEE IS NON-REFUNDABLE

Printed Name of Card Holder

SECTION 8
APPLICANT'S
SIGNATURE
Sign in ink

I certify that the foregoing information furnished on this application is true and correct.
Signature of applicant (sign in ink)

Date

Print or type name and title of applicant
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.
NEW - Page 2

Form - 224A

APPLICATION FOR REGISTRATION

SUPPLEMENTARY INSTRUCTIONS AND INFORMAITON

SECTION 1. UPDATE REGISTRATION INFORMATION
Each data field displays the information we have on record for your registration. Fill in blanks, update and correct data in the blocks provided. A physical address is
required in address line 1; a post office box or continuation of address may be entered in address line 2. Fee exempt applicant must list the address of the federal
or state fee exempt institution.
Applicant must enter a valid social security number (SSN), or a tax identification number (TIN) if applying as a business entity. Debt collection information is
mandatory pursuant to the Debt Collection Improvement Act of 1996.
The email address, point of contact, national provider id, date of birth, year graduated, and professional school are new data items that are used to facilitate
communication or as required by inter-agency data sharing requirements. They are requested in order to facilitate communication or as required by inter-agency
data sharing requirements.
Practitioners must enter one degree from this list: DDS, DMD, DO, DPM, DVM, or MD.
Mid-level practitioners must enter one degree from this list: DOM, HMD, MP, ND, NP, OD, PA, or RPH.
IF ALL THE DATA IS CORRECT AND COMPLETE, THEN SKIP TO SECTION 2.
SECTION 2. DRUG SCHEDULES.
Check the order form box only if you intend to purchase or transfer schedule 2 controlled substances. Order forms will be mailed to the registered address following
issuance of a Certificate of Registration.
All the drug schedules you were certified for on previous registration are displayed above the dotted line. If you are registering for the same schedule(s) listed,
CHECK THE "NO CHANGE" BOX AND THEM SKIP TO SECTION 3.
If you need to make a change, applicant should check all drug schedules to be handled from the list displayed below the dotted line. However, applicant must still
comply with state requirements; federal registration does not overrule state restrictions.
The following list of drug codes are examples of controlled substances for narcotic and non-narcotic schedules 2, 3, 4, and 5.
Refer to the CFR for a complete list of basic classes.
SCHEDULE 2 NARCOTIC

BASIC
CLASS

SCHEDULE 3 NARCOTIC

BASIC
CLASS

SCHEDULE 4

BASIC
CLASS

Alphaprodine (Nisentil)

9010

Buprenorphine (Buprenex, Temgesic, Subutex

9064

Alprzolam (Xanax)

2882

Anileridine (Leritine)

9020

Codeine combo product up to 90 mg/du (Empirin)

9804

Barbital (Veronal, Plexonal, Barbitone)

2145

Cocaine (Methyl Benzoylecgonine)

9041

Dihydrocodeine combo prod 90 mg/du (Compal)

9807

Chloral Hydrate (Noctec)

2465

Codeine (Morphine methyl ester)

9050

Ethylmorphine combo product 15 mg/du

9808

Chlordiazepoxide (Librium, Libritabs)

2744

Dextropropoxyphene (bulk)

9273

Hydrocodone combo product (Lorcet, Vicodin)

9806

Clorazepate (Tranxene)

2768

Diphenoxylate

9170

Morphine combo product 50 mg/100ml or gm

9810

Dextropropoxyphene du (Darvon)

9278

Diprenorphine (M50-50)

9058

Opium combo product 25 mg/du (Paregoric)

9809

Diazepam (Valium, Diastat)

2765

Ethylmorphine (Dionin)

9190

SCHEDULE 3 NON-NARCOTIC

BASIC
CLASS

Diethylpropion (Tenuate, Tepanil)

1610

Etorphine Hydrochloride (M-99)

9059

Anabolic Steroids

4000

Difenoxin 1mg/25ug atropine SO4/du (Motofen)

9167

Glutethimide (Doriden, Dorimide)

2550

Benzphetamine (Didrex, Inapetyl)

1228

Fenfluramine (Pondimin, Dexfenfluramine)

1670

Hydrocodone (Dihydrocodeinone)

9193

Butalbital (Fiorinal, Butalbital w/aspirin)

2100/2165

Flurazepam (Dalmane)

2767

Hydromorphone (Dialudid)

9150

Dronabinol in sesame oil w/soft gelatin capsule

7369

Halazepam (Paxipam)

2762

Levo-alphacetylmethadol (LAAM)

9648

Gamma Hydroxbutyric Acid preps (Zyrem)

2012

Lorazepam (Ativan)

2885

Levorphanol (Levo-Dromoran)

9220

Ketamine (Ketaset)

7285

Mazindol (Sanorex, Mazanor)

1605

Meperidine (Demerol, Mepergan)

9230

Methyprylon (Noludar)

2575

Mebutamate (Capla)

2800

Methadone (Dolophine, Methadose)

9250

Pentobarbital suppository du & noncontrolled active ingred. (FP-3, WANS)

2271

Meprobamate (Miltown, Equanil)

2820

Morphine (MS Contin, Roxanol)

9300

Phendimetrazine (Plegine, Bontril, Statobex

1615

Methohexital (Brevital

2264

Opium, powdered

9639

Secobarbital suppository du & noncontrolled active ingredients

2316

Methylphenobarbital (Mebaral)

2250

Opium, raw

9600

Thiopental (Pentothal)

2100/2329

Midazolam (Versed)

2884

Oxycodone (Oxycontin, Percocet)

9143

Vinbarbital (Delvinal)

2100/2329

Oxazepam (Serax, Serenid-D))

2835

Oxymorphone (Numorphan)

9652

Paraldehyde (Paral)

2585

Opium Poppy / Poppy Straw

9650

SCHEDULE 5

BASIC
CLASS

Pemoline (Cylert)

1530

Poppy Straw Concentrate

9670

Codeine Cough Preparation (Cosanyl, Pediacof)

9050

Pentazocine (Talwin, Talacen)

9709

Thebaine

9333

Difenoxin Preparation (Motofen)

9167

Phenobarbital (Luminal, Donnatal)

2285

SCHEDULE 2 NON-NARCOTIC

BASIC
CLASS

Dihydrocodeine Preparation (Cophene-S)

9120

Phentermine (Ionamin, Fastin, Zantryl)

1640

Amobarbital (Amytal, Tuinal)

2125

Diphenoxylate Preparation (Lomotil, Logen)

9170

Prazepam (Centrax)

2764

Amphetamine (Dexedrine, Adderall)

1100

Ethylmorphine Preparation

9190

Quazepam (Doral)

2881

Methamphetamine (Desoxyn)

1105

Opium Preparation (Kapectolin PG)

9809

Temazepam (Restoril)

2925

Methylphenidate (Concerta, Ritalin)

1724

Triazolam (Halcion)

2887

Pentobarbital (Nemutal)

2270

Zolpidem (Ambien, Ivadal, Stilnox)

2783

Phencyclidine (PCP)

7471

Phenmetrazine (Preludin)

1631

Phenylacetone

8501

Secobarbital (Seconal)

2315

RENEWAL INST - Page 3

Form - 224A

APPLICATION FOR REGISTRATION

SUPPLEMENTARY INSTRUCTIONS AND INFORMAITON

- CONTINUED SECTION 3. STATE LICENSE(S) Federal registration by DEA is based upon the applicant 's compliance with applicable state and local laws. Applicant should contact the local state licensing
authority prior to completing this application. If your state requires a separate controlled substance number, provide that number on this application.
SECTION 4. LIABILITY Applicants must answer all four questions for the application to be accepted for processing.
If you answer "Yes" to a question, provide an explanation in the space provided.
If you answer "Yes" to several of the questions, then you must provide a separate explanation describing the date, location, nature, and result of each incident.
If the "Yes" box is already marked, then we have that data no record from a previous registration. You must provide an explanation for the original and all
subsequent [new] incidents. If additional space is required, you may attach a separate page.
SECTION 5. EXEMPTION FROM APPLICATION FEE Exemption from payment of application fee is limited to federal, state or local government official or institution. The applicant's superior or agency officer must certify
exempt status. The signature, authority title, and telephone number of the certifying official (other than the applicant) must be provided. The address of the fee
exempt institution must appear in Section 1.
SECTION 6. METHOD OF PAYMENT Indicate the desired method of payment. Make checks payable to "Drug Enforcement Administration". Third-party checks or checks drawn on foreign banks will not
be accepted. FEES ARE NON-REFUNDABLE.
SECTION 7. APPLICANT'S SIGNATURE Applicant MUST sign in this section or application will be returned. Card holder signature in section 6 does not fulfill this requirement.
Notice to Registrants Making Payment by Check
Authorization to Convert Your Check: If you send us a check to make your payment, your check will be converted into an electronic fund transfer. "Electronic fund transfer"
is the term used to refer to the process in which we electronically instruct your financial institution to transfer funds from your account to our account, rather than processing
your check. By sending your completed, signed check to us, you authorize us to copy your check and to use the account information from your check to make an electronic
fund transfer from your account for the same amount as the check. If the electronic fund transfer cannot be processed for technical reasons, you authorize us to process the
copy of your check.
Insufficient Funds: The electronic funds transfer from your account will usually occur with 24 hours, which is faster than a check is normally processed. Therefore, make
sure there are sufficient funds available in your checking account when you send us your check. If the electronic funds transfer cannot be completed because of insufficient
funds, we may try to make the transfer up to two times.
Transaction Information: The electronic fund transfer from your account will be on the account statement you receive from your financial institution. However, the transfer
may be in a different place on your statement than the place where your checks normally appear. For example, it may appear under "other withdrawals" or "other
transactions." You will not receive your original check back from your financial institution. For security reasons, we will destroy your original check, but we will keep a copy of
the check for record-keeping purposes.
Your Rights: You should contact your financial institution immediately if you believe that the electronic fund transfer reported on your account statement was not properly
authorized or is otherwise incorrect. Consumers have protections under Federal law called the Electronic Fund Transfer Act for an unauthorized or incorrect electronic fund
transfer.
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 control number. The
OMB number for this collection is 1117-0014. Public reporting burden for this collection of information is estimated to average 12 minutes 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 (PL 104-134) requires that you furnish your Taxpayer Identification Number and/or Social Security Number on this
application. This number is required for debt collection procedures if your fee is not collectible.
4.
PRIVACY ACT INFORMATION
AUTHORITY: Section 302 and 303 of the Controlled Substances Act of 1970 (PL 91-513) and Debt Collection Improvements Act of 1996 (PL 104-134) for SSN and/or
TIN
PURPOSE: To obtain information required to register applicants pursuant to the Controlled Substances Act of 1970
ROUTINE USES: The Controlled Substances Act registration system produces special reports as required for statistical analytical purposes. Disclosures of Information
from this system are made to the following:
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 (PL 91-513) for the purpose of verifying registration
EFFECT: Failure to complete form will preclude processing of the application.
Your Local
INTERNET
CONTACT INFORMATION
DEA Office
www.deadiversion.usdoj.gov
TELEPHONE
All offices are listed on web site
HQ Call Center (800) 882-9539
(800, 877, and 888 are toll-free
WRITTEN INQUIRIES:
DEA, Attn: Registration Section / ODR,
P.O. Box 2639, Springfield, VA 22152-2639

RENEWAL INST - Page 4