Form DEA-510 Application for Registration

APPROVED OMB NO 1117-0031
FORM DEA-510 (10-06)
Previous editions are obsolete

APPLICATION FOR REGISTRATION

Form-510

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. Print clearly, using black or blue ink, or use a typewriter.
3. Mail this form to the address provided in Section 7 or use enclosed envelope.
4. Include the correct payment amount. FEE IS NON-REFUNDABLE.
5. If you have any questions call 800-882-9539 prior to submitting your application.

Do you have other DEA registration numbers?
NO

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

MAIL-TO ADDRESS

SECTION 1

YES

FEE FOR ONE (1) YEAR - see Section 2
FEE IS NON-REFUNDABLE

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

APPLICANT IDENTIFICATIION

Name 1

(Business or Facility Name)

Name 2

(Continuation of business name)

Street Address Line 1 (if applying for fee exemption, this must be address of the fee exempt institution)

Address Line 2

City

State

Business Phone Number

Point of Contact

Business Fax Number

Email Address

DEBT COLLECTION
INFORMATION

Zip Code

Tax Identification Number
See additional information
note #3 on page 4.

Mandatory pursuant
to Debt Collection
Improvements Act

SECTION 2
BUSINESS ACTIVITY

Chemical Distributor........fee for one year is $1147

Chemical Importer...............fee for one year is $1147

Check one
business activity
box only

Chemical Exporter...........fee for one year is $1147

Chemical Manufacturer........fee for one year is $2293

SECTION 3
A.
SCHEDULES

X

List 1 chemicals

Enter specific codes
on page 2.
B.
MANUFACTURERS
ONLY
Mark the appropriate
box with an 'X' to indicate
if List 1 chemicals
are handled in bulk
or dosage form.

LIST 1

STAGE 1
Bulk synthesis/extraction

LIST 1
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STAGE 2
Dosage form manufacture

SECTION 4

Enter your state license information if you are currently authorized to manufacture distribute, import, or export the listed chemicals
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

NOT REQUIRED
by this state

Expiration
Date

/

/

MM - DD ­ YYYY

What state was this license issued in?

SECTION 5
LIABILITY

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

IMPORTANT
All questions in
this section must
be answered.

YES

NO

YES

NO

YES

NO

YES

NO

1. Has the applicant ever been convicted of a crime in connection with listed chemical(s) under state or federal law,
or is any such action pending?

2. Has the applicant ever surrendered (for cause) or had a federal 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 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
listed chemical(s) under state or federal law, or ever surrendered, for cause, or had a federal listed chemical/controlled
registration revoked, suspended, restricted, denied, or ever had a state professional license or controlled substance
substance registration revoked, suspended, denied, restricted or placed on probation, or is any such action pending?
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.

Date(s) of incident MM-DD-YYYY:
EXPLANATION OF
"YES" ANSWERS
Applicants who have
answered "YES" to
any of the four questions
above must provide
a statement to explain
each "YES" answer.

Liability question #

Location(s) of incident:

Nature of incident:

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

U.S. Department of Justice
Drug Enforcement Administration
P.O. Box 28083
Washington, DC 20038-8083

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: 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 the application is subject to imprisonment for not more than four years, a fine of not more than $30,000, or both.
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