Form 224 Application for Registration

APPROVED OMB NO 1117-0014
FORM DEA-224 (10-20)

APPLICATION FOR REGISTRATION

Form-224

Under the Controlled Substances Act

DEA OFFICIAL USE :

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

INSTRUCTIONS

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?
NO

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

MAIL-TO ADDRESS

SECTION 1

FEE FOR THREE (3) YEARS IS $888
FEE IS NON-REFUNDABLE

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

APPLICANT IDENTIFICATION

Individual Registration

Name 1

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

Name 2

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

YES

Business Registration

PLACE OF BUSINESS Street Address Line 1

PLACE OF BUSINESS Address Line 2

City

State

Zip Code

Business Phone Number

Point of Contact

Cell Phone Number

Email Address (one email address only, this address is for receiving renewal and other registration notices)

DEBT COLLECTION
INFORMATION

Social Security Number (if registration is for individual)

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

Professional Degree

Professional

Year of
Graduation:

(select from list only):
School:
FOR
Practitioner
or
MLP
National Provider Identification:
ONLY:

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

SECTION 2

BUSINESS ACTIVITY
Check one
business activity
box only

Central Fill Pharmacy

Automated Dispensing System (ADS)

Y Y
Ambulance Service

Practitioner Military

Emergency Medical Services

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

Animal Shelter

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

Hospital/Clinic Teaching

Euthanasia Technician

Institution

Mid-level Practitioner (MLP)

Nursing Home

Y Y

Practitioner

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

Retail Pharmacy

FOR Automated Dispensing System
(ADS) ONLY:

D D

DEA Registration #
of Retail Pharmacy
for this ADS

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

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.

224 - Page 1

SECTION 4
STATE LICENSE

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.

MANDATORY

State License Number:

Expiration Date:

/
/
_______________
MM - DD - YYYY

Which state or jurisdiction issued this license? _______________________________

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 is any such action
pending?
Date(s) of incident MM-DD-YYYY: _________________________________

YES

NO

YES

NO

2. Has the applicant ever 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: _________________________________
YES NO
3. 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: _________________________________
4. 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: _________________________________

YES

NO

YES

NO

5. 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: _________________________________ Note: If question 5 does not apply to you, be sure to mark 'NO'.
Liability question #

EXPLANATION OF
"YES" ANSWERS
Applicants who have
answered “YES” to any
question above must
provide an explanation.

Location(s) of incident:

Nature of incident (if necessary, attach a separate sheet and return with application):

Disposition of incident:

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.

FEE EXEMPT
CERTIFIER
Provide the name,
email and phone
number of the
certifying official

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.
Signature of certifying official (other than applicant)

Date

Print or type name and title of certifying official

Telephone No. (required for verification)

Email address of certifying official

SECTION 7
METHOD OF
PAYMENT

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:
DEA Headquarters
ATTN: Registration Section/DRR
P.O. Box 2639
Springfield, VA 22152-2639

Visa
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.
224 - Page 2

SECTION 4
STATE LICENSE(S)
MANDATORY
Be sure to include both
state license numbers

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 Number

Expiration
Date

/
/
_______________
MM - DD - YYYY

State Controlled Substance
License Number

Expiration
Date

/
/
_______________
MM - DD - YYYY

Which state or jurisdiction issued these licenses?

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 is any such
action pending?
Date(s) of incident MM-DD-YYYY: _________________________________

2. Has the applicant ever 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: _________________________________
3. 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: _________________________________
4. 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: _________________________________

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

5. 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: _________________________________ Note: If question 5 does not apply to you, be sure to mark 'NO'.
EXPLANATION OF
"YES" ANSWERS
Applicants who have
answered “YES” to
any question above
must provide an
explanation.

Liability question #

Location(s) of incident:

Nature of incident (if necessary, attach a separate sheet and return with application):

Disposition of incident:

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

DEA Headquarters
ATTN: Registration Section/DRR
PO 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.
224 - Page 2

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 five 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 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 FROM 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.
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.
Insufficient Funds: The electronic funds transfer from your account will usually occur within 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 more two 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.
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
0MB control number. The 0MB 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 principal 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

INTERNET:

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

TELEPHONE :

www.deadiversion.usdoj.gov
HQ Call Center (800)882-9539

WRITTEN INQUIRIES:
DEA
Attn: Registration Section/DRR
P.O. Box 2639
Springfield, VA 22152-2639