DEA-363A Application for Registration Renewal

RENEWAL APPLICATION FOR REGISTRATION

form-36 3A
Renewa 1

Under the Narcotic Addict Treatment Act of 1974

INSTRUCTIONS

To renew by mail complete this application. Keep a copy for your records.
Mail this form to the address provided in Section 6 or use enclosed envelope.
The "MAIL-TO ADDRESS" can be different than your "PLACE OF BUSINESS" address.
If you have any questions call 800-882-9539 prior to submitting your application.

IMPORTANT: DO NOT SEND THIS APPLICATION

MAIL-TO ADDRESS

SECTION 1

Form Expires: 6/30/18

Save time - renew on-line at www.deadiversion.usdoj.gov
1.
2.
3.
4.

AND RENEW ON-LINE.

APPROVED 0MB NO 1117-0015
FORM DEA-363A (05-17)

REGISTRATION INFORMATION:
DEA#
REGISTRATION EXPIRES
FEE IS NON-REFUNDABLE

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

UPDATE REGISTRATION INFORMATION - Please fill in missing information and make corrections if needed to any data we have on record for your registration.

Name 1:

Name 2:

PLACE OF
U

6. SINESS
street ,,,.........·.::···········,,...........·,:···········:::···········::··w····::············,,...........,,,...........,,·.·········,,,...........,,...........,,,...........,,..........·,:············,,...........,,,...........,,...........,,...........·,:···········:,,...........,,............,,·.·········,,...........,,,...........,,...........,,,..........·,:···········:,,...........,,............,,...........,,...........,,,...........,,............,,...........,,...........,,,...........,,............,,...........,,...........,,,
Address
Line 1

PLACE OF
BUSINESS ,,,,.,.,.,.,.,,,.,.,.,.,.,.,,,.,.,.,.,.,.,,,.,.,.,.,.,,,,,.,.,.,.,.,,,.,.,.,.,.,.,,,.,.,.,.,.,.,,,.,.,.,.,.,,,,,.,.,.,.,.,,,.,.,.,.,.,.,,,.,.,.,.,.,.,,,.,.,.,.,.,,,,,.,.,.,.,.,,,.,.,.,.,.,.,,,.,.,.,.,.,.,,,.,.,.,.,.,,:,:.,.,.,.,.,,,.,.,.,.,.,.,,,.,.,.,.,.,.,,,.,.,.,.,.,,,,,.,.,.,.,.,,,.,.,.,.,.,.,,,.,.,.,.,.,.,,,.,.,.,.,.,,,,,.,.,.,.,.,,,.,.,.,.,.,.,,,.,.,.,.,.,.,,,.,.,.,,.,.,,,,,.,.,.,.,.,,,.,.,.,.,.,.,,,.,.,.,.,.,.,,,.,.,.,.,.,,,,,.,.,.,.,.,,,.,.,.,.,.,.,,,.,.,.,.,.,.,,,.,.,.,.,.,,,,,.,.,.,.,.,,,.,.,.,.,.,.,,,.,.,.,.,.,.,,,.,.,.,.,.,,,,

Address
Line 2:
City
State :
Zip

Business
Phone
Number:

Cell
Phone
Number:

Point of
Contact:

EMAIL
Address :

Tax Identification Number

DEBT COLLECTION
INFORMATION
Mandatory pursuant
to Debt Collection
Improvements Act

SECTION 2
DRUG SCHEDULES

See additional information
note #3 on page 4.

Check this box if you wish to register for the same schedule(s):

Check this box if you require official order forms:

NO CHANGE
For purchase of schedule 2 controlled substances
2,
-0�--------------------------------------------------------------CHANGE

If you want to make a change, check all the schedules that you are requesting for this registration:
Schedule 2 Narcotic

[::]s chedule 3 Narcotic