236 Controlled Substances Import/Export Declaration

Please complete page 1 only. The remaining copies will be generated automatically.
U.S. Department of Justice / Drug Enforcement Administration

CONTROLLED SUBSTANCES IMPORT / EXPORT DECLARATION

OMB Approval No. 1117-0009
Expiration Date: 10/31/2018

(read instructions and Privacy Act before completing)
Type of Declaration:
IMPORT
EXPORT

Non-narcotic substances in Schedules III, IV, or V
Non-narcotic substances in Schedules III or IV and all substances in Schedule V

DEA Transaction No.*:
Date of Issue:
Date of Expiration:

*This declaration is not deemed filed, and therefore is not valid, until the Drug Enforcement Administration (DEA) has issued a DEA Transaction number
1b. Broker/Forwarding Agent (company name and address)

1a. Importer/Exporter (U.S. company name and address)

DEA Registration No.:
2. Controlled Substances to be Imported or Exported
2a. Name and quantity of drug or preparation (name on
labels; number and size of packages; strength of drug or
preparation; CSA Drug Code; NDC Number)

2b. Controlled substance content of drug/preparation and
weight calculation expressed in base and acid or alkaloid

3a. Port of Export:
and anticipated Date of Departure:

2c. Return Information
(see instructions)

3b. Port of Import:
and anticipated Date of Arrival:

4. Mode of Transport and name(s) of carrier or vessel:
5. Foreign Consignee/Consignor (company name and address)

Foreign Import Permit No.:
Date of Issue:
Date of Expiration:
(Required for U.S. exports)

Reference No.:
I hereby certify the substances listed in Section 2 are to be:
Imported (conforms to 21 U.S.C. § 952(b))
Exported (conforms to 21 U.S.C. § 953(e))
Scientific, or
and are intended for
Medical
Other legitimate uses (attach explanation for other legitimate uses.)
The substances listed in Section 2 will be Re-Exported to: (attached documentation per Title 21 C.F.R. § 1312.27(b)(5))
If this form is being used as an "Export Declaration", attach doucumentation the consignee is authorized under the laws and regulations of the country of destination to
receive the controlled substances. If the controlled substances are being re-exported from the first country to second countries, attach documentation the consignee(s) in
the country of ultimate destination is authorized under the laws and regulations of that country to receive the controlled substances.

Signature of Authorized Individual of Importer/Exporter, Broker, or
Forwarding agent
Print Name:

Name of Firm and contact information of person submitting DEA Form-236

Date:

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DEA Form-236

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