224 Dea

APPROVED OMB NO 1117-0014
FORM DEA-224 (04-12)
FORM EXPIRES: 01/31/2016

APPLICATION FOR REGISTRATION

Form-224

Under the Controlled Substances Act

INSTRUCTIONS

Save time - apply on-line at www.deadiversion.usdoj.gov

DEA OFFICIAL USE :

1. To apply by mail complete this application. Keep a copy for your records.
2. Mail this form to the address provided in Section 7 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.

Do you have other DEA registration numbers?

IMPORTANT: DO NOT SEND THIS APPLICATION AND APPLY ON-LINE.

MAIL-TO ADDRESS

SECTION 1

Name 2

(First Name and Middle Name of individual - OR- Continuation of business name)

State

SA
M

City

PL

(Last Name of individual -OR- Business or Facility Name)

PLACE OF BUSINESS Address Line 2

Business Phone Number

Point of Contact

Business Fax Number

Email Address

Social Security Number (if registration is for individual)

SECTION 2

BUSINESS ACTIVITY
Check one
business activity
box only

Zip Code

Tax Identification Number (if registration is for business)

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

Mandatory pursuant
to Debt Collection
Improvements Act
FOR
Practitioner
or
MLP
ONLY:

Business Registration

E

Individual Registration

Name 1

PLACE OF BUSINESS Street Address Line 1

YES

FEE FOR THREE (3) YEARS IS $731
FEE IS NON-REFUNDABLE

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

APPLICANT IDENTIFICATION

DEBT COLLECTION
INFORMATION

NO

Professional
Degree :

Professional
School :

select from
list only

National Provider Identification:

Central Fill Pharmacy
Retail Pharmacy

Nursing Home
Automated Dispensing System (ADS)

FOR Automated Dispensing System
(ADS) ONLY:

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

D D

Practitioner

Y Y

Y Y

(DDS, DMD, DO, DPM, DVM, or MD)

Ambulance Service

(DDS, DMD, DO, DPM, DVM, or MD)

Animal Shelter

(DOM, HMD, MP, ND, NP, OD, PA, or RPH)

Hospital/Clinic

Euthanasia Technician

Teaching Institution

Practitioner Military

Mid-level Practitioner (MLP)

An ADS is automatically fee-exempt.
Skip Section 6 and Section 7 on page 2.
You must attach a notorized affidavit.

DEA Registration #
of Retail Pharmacy
for this ADS

SECTION 3

Schedule 2 Narcotic

Schedule 3 Narcotic

Schedule 4

Check all that apply

Schedule 2 Non-Narcotic (2N)

Schedule 3 Non-Narcotic (3N)

Schedule 5

DRUG SCHEDULES

Check this box if you require official order forms - for purchase of schedule 2 controlled substances.

NEW - Page 1

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:

E

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:
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

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.

SA
M

SECTION 6

YES

PL

EXPLANATION OF

"YES" ANSWERS

/

MM - DD - YYYY

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

IMPORTANT

/

MM - DD - YYYY

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:

E

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:
Liability question #

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

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.

SA
M

SECTION 6

NO

PL

EXPLANATION OF

"YES" ANSWERS

YES

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

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:

E

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:

PL

EXPLANATION OF

"YES" ANSWERS

Liability question #

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

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.

SA
M

SECTION 6

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.

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.

Form - 224

APPLICATION FOR REGISTRATION

SUPPLEMENTARY INSTRUCTIONS AND INFORMATION

SECTION 1. APPLICANT IDENTIFICATION - Information must be typed or printed in the blocks provided to help reduce data entry errors. 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.
Practitioner must enter one degree from this list: DDS, DMD, DO, DPM, DVM, or MD.
Mid-level practitioner must enter one degree from this list: DOM, HMD, MP, ND, NP, OD, PA, or RPH.
SECTION 2. BUSINESS ACTIVITY - Indicate only one. Practitioner or mid-level practitioner must enter the degree conferred, and are requested to enter the last
professional school of matriculation and the year graduated.

PL

E

Automated dispensing system (ADS) must provide current DEA registration number of parent retail pharmacy or hospital, and attach a notarized affidavit in
accordance with 21 CFR Part 1301.17. Affidavit must include:
1. Name of parent retail pharmacy or hospital and complete address
2. Name of Long-term Care (LTC) facility and complete address
3. Permit or license number(s) and date issued of State certification to operate ADS at named LTC facility
4. Required Statement:
This affidavit is submitted to obtain a DEA registration number. If any material information is false, the Administrator may commence proceedings to deny the
application under section 304 of the Act (21 U.S.C. 8224(a)). Any false or fraudulent material information contained in this affidavit may subject the person signing
this affidavit, and the named corporation/partnership/business to prosecution under section 403 of the Act (21 U.S.C 843).
5. Name of corporation operating the retail pharmacy or hospital
6. Name and title of corporate officer signing affidavit
7. Signature of authorized officer
SECTION 3. DRUG SCHEDULES - Applicant should check all drug schedules to be handled. However, applicant must still comply with state requirements; federal
registration does not overrule state restrictions. Check the order form box only if you intend to purchase or to transfer schedule 2 controlled substances. Order forms will be
mailed to the registered address following issuance of a Certificate of Registration. 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.
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

SA
M

SCHEDULE 2 NARCOTIC

NEW INST - Page 3

Form - 224

APPLICATION FOR REGISTRATION
- CONTINUED -

SUPPLEMENTARY INSTRUCTIONS AND INFORMATION

SECTION 4. 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 5. LIABILITY - Applicant 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 additional space is required, you may attach a separate page.
SECTION 6. EXEMPTION 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 7. 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 8. APPLICANT'S SIGNATURE - Applicant MUST sign in this section or application will be returned. Card holder signature in section 7 does not fulfill this
requirement.

E

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.

PL

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 more 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.

SA
M

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

No registration will be issued unless a completed application has been received (21 CFR 1301.13).
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 OMB 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.

The Debt Collection Improvements Act of 1996 (31 U.S.C. §7701) requires that you furnish your Taxpayer Identification Number (TIN) or Social Security Number (SSN) on
this application. This number is required for debt collection procedures if your fee is not collectible.
PRIVACY ACT NOTICE: Providing information other than your SSN or TIN is voluntary; however, failure to furnish it will preclude processing of the application. The
authorities for collection of this information are §§302 and 303 of the Controlled Substances Act (CSA) (21 U.S.C. §§822 and 823). The principle purpose for which the
information will be used is to register applicants pursuant to the CSA. The information may be disclosed to other Federal law enforcement and regulatory agencies for law
enforcement and regulatory purposes, State and local law enforcement and regulatory agencies for law enforcement and regulatory purposes, and persons registered under
the CSA for the purpose of verifying registration. For further guidance regarding how your information may be used or disclosed, and a complete list of the routine uses of this
collection, please see the DEA System of Records Notice "Controlled Substances Act Registration Records" (DEA-005), 52 FR 47208, December 11, 1987, as modified.
Your Local
DEA Office

CONTACT INFORMATION

All offices are listed on web site
(800, 877, and 888 are toll-free)

INTERNET
www.deadiversion.usdoj.gov
TELEPHONE
HQ Call Center (800) 882-9539
WRITTEN INQUIRIES:
DEA
Attn: Registration Section/ODR
P.O. Box 2639
Springfield, VA 22152-2639

NEW INST - Page 4