Form 161 Application for Permit to Export Controlled Substances

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

APPLICATION FOR PERMIT TO EXPORT CONTROLLED SUBSTANCES

PURSUANT TO SECTION 1003(a), (b), (c) & (d), TITLE III, PL 91-513

(See Reverse for Instructions and Privacy Act Information)
TO

DATE

Drug Enforcement Administration
Office of Diversion Control
International
Unit (ODOI)
Import
/ ExportDrug
Unit (ODGI)
Washington,
D.C.
20537
8701
Morrissette
Drive
Springfield, VA 22152

EXPORTER’S APPLICATION NUMBER

Application is hereby made pursuant to the provisions of the Controlled Substances Import and Export Act and the
regulations prescribed thereunder for a permit to export as follows:
1. NAME OF CONSIGNEE

2. ADDRESS OF CONSIGNEE

3. BUSINESS OF CONSIGNEE

4. FOREIGN PORT OF ENTRY (City & Country)

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

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

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

NO.

ISSUE DATE:

5c. APPROX. DATE OF EXPORTATION

DATED

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 EXPORTED AND ACTUAL
QUANTITY (Completed by
registrant at time of export)
DEA PERMIT NO.:

The packages to be exported are labeled in conformance with 21 C.F.R. Part 302 and, to the best of my knowledge and belief, the importing country has instituted
and maintains a system for the control of these substances; the drugs are consigned to a holder of such permits or licenses as may be required under the laws of the
country of import; the substances are to be applied exclusively to medical or scientific uses within the country of import; there is an actual need for the controlled
substances for medical or scientific uses within such country ; the substances will not be re-exported therefrom; except, in the case of bulk cocaine alkaloid, the
substance will be processed within the country of import and the products therefrom may be re-exported in accordance with Paragraph 2, Article 31 of the Single
Convention on Narcotic Drugs, 1961.
NAME OF EXPORTER

ADDRESS OF EXPORTER
EXPORTER’S DEA REGISTRATION NO .

EXPORTER’S TELEPHONE NO.

NOTICE:

DEA USE ONLY

SIGNATURE AND TITLE OF PERSON MAKING APPLICATION

Controlled Substances may not be exported by mail or parcel post.

APPROVED EXPORT PERMIT NUMBER

FORM DEA-161 (6-01) Previous editions are obsolete

DATE EXPORT PERMIT NUMBER ISSUED

INSTRUCTIONS AND INFORMATION, DEA-161

This application must be completed in triplicate. Original is sent to DEA. See instruction (7) 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 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 as exporters may be issued export permits. The registrations of manufacturers, distributors,
practitioners, researchers, etc., do not entitle them to export controlled substances.
(5) 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.
(6) Identification of drugs to be exported and the controlled substance content should be entered on the application in the

following manner:
7a. NAME AND QUANITY OF DRUG OR PREPARATION
TO BE EXPORTED

7B. CONTROLLED SUBSTANCE CONTENT OF DRUG OR PREPARATION
TO BE EXPORTED (expressed as acid, base or alkaloid, not salt)

3 bottles x 100 Secobarbital Sodium capsules (100 mg./capsule)

Secobarbital

27.47 Gm.

2 boxes x 100 Medperidine HCL ampules (5%, 2ml. ampules)

Meperidine

17.43 G.m

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

Meperidine

174.30 Gm.

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

8.24 Gm.
73.38 Gm.
1.77 Gm.

(7) The following information must be entered in block 7c at the time of export: (1) DEA Export Permit Number
and (2) actual quantity and date shipped. Copy 2 is sent to DEA, and Copy 3 is retained by the registrant.

PRIVACY ACT INFORMATION
AUTHORITY: Section 1003 of the Controlled Substances Act of 1970 (PL 91-513).
PURPOSE: Control exportation of certain Controlled Substances into 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 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 regulatorypurposes.
C. Persons registered under the Controlled Substances Act (Public Law 91-513)
for the purpose of verifying the registration of customers and practioners.

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 valis OMB control number for this Information Collection is
1117-0004. The time required the complete this information collection is estimated to average 15 minutes per response,
including the time to review instructions, search existing data resources, gather the data needed, and complete and
review the information collection.