DEA 224B Affidavit for Chain renewal

DEA Form – 224B

Affidavit for Chain Renewal
DEA Retail Pharmacy Registrations

OMB No. 1117-0014
Expiration date:
(MM/DD/YYYY)

Privacy Act Information
AUTHORITY: Section 302 and 303 of the Controlled Substances Act of 1970 (PL 91-513).
PURPOSE: To obtain information required to register applicants pursuant to the Controlled Substances Act of 1970.
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 purposes stated:
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 the registration of customers and
practitioners.
EFFECT: Failure to complete form will preclude processing of the application.
WARNING: Section 843(a)(4)(A) of Title 21, United States Code, states that any person who knowingly or intentionally furnishes false or fraudulent information in
this application affidavit is subject to imprisonment for not more than four years, a fine of not more than $30,000.00 or both.
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.
Public reporting burden for this collection of information is estimated to average 5 hours per response, including the time of reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this
burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Drug Enforcement Administration, FOI
and Records Management Section, Washington, D.C. 20537; and to the Office of Management and Budget, Paperwork Reduction Project No. 1117-0014,
Washington, D.C. 20503.

Mail the original of the attached with the fee made payable by check or money order to the Drug Enforcement Administration
to:
REGISTRATION CHAIN RENEWAL
United States Department of Justice
Drug Enforcement Administration
Registration Section/ ODR
P.O. Box 2639
Springfield, VA 22152-2639

DEA Form - 224B

Affidavit for Chain Renewal
DEA Retail Pharmacy Registrations

OMB No. 1117-0014
Expiration date:
(MM/DD/YYYY)

No registration may be issued unless a completed application form has been received (21 CFR 1301.13). This affidavit is
provided in lieu of a separate DEA application form for each registration on the attached list.
I hereby certify that the answers to the questions below pertain to each of the registrations on the attached list in the
category of retail pharmacy for the
(a) Are the listed locations currently authorized to prescribe, distribute, dispense, conduct research, or otherwise handle controlled
substances in the schedules for which they currently are authorized on their DEA registration under the laws of the State or jurisdiction
in which they are operating?
[ ] Yes
[ ] No
(b) Has the applicant ever been convicted of a crime in connection with controlled substances under State or Federal law, or ever
surrendered or had a State professional license or controlled substance registration revoked, suspended, denied, restricted, or placed
on probation, or is any such action pending against the applicant?
[ ] Yes
[ ] No
(c) 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 substances
under State or Federal law, or ever surrendered or had a Federal controlled substance registration revoked, suspended, restricted or
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 against the applicant?
[ ] Yes
[ ] No
IF THE ANSWER TO QUESTIONS (b) or (c) IS YES FOR ANY LOCATION, INCLUDE A STATEMENT EXPLAINING SUCH
RESPONSE(S).
________________________________________________
Signature of authorized individual (must be an original ink
signature)

___________________
Date

_______________________________________________
Title of the person signing on behalf of the applicant

______________________________
Applicants Business Phone Number

The application fee for the applicants on the attached is $
Fees are not refundable.