Form DEA Form 250 DEA Form 250 Application for Procurement Quota for Controlled Substan

APPLICATION FOR PROCUREMENT QUOTA

U.S. Department of Justice
Drug Enforcement Administration

No procurement quota may be issued unless a completed application form has
been received, 21 CFR 1303.12(b)

SEE INSTRUCTIONS ON
SEPARATE PAGE

1. NAME OF BASIC CLASS OR LIST I CHEMICAL (Only one per DEA–250)

OMB Approval
No. 1117-0008

2. SCHEDULE / LIST
NUMBER

3. DEA DRUG / CHEMICAL CODE NUMBER

4. NAME AND ADDRESS OF REGISTRANT (Include No., Street, City, State and ZIP Code)

5. YEAR FOR WHICH QUOTA IS
REQUESTED
6. DEA MANUFACTURING REGISTRATION
NUMBER

7. NAME OF CONTACT PERSON

8. TELEPHONE No. (Include extension)

9. FAX No.

10. E-MAIL ADDRESS

NOTE: All quantities are to be expressed in grams of anhydrous acid, base, or alkaloid (not as salts).
QUOTAS PREVIOUSLY ISSUED BY DEA

11. QUOTA HISTORY
2

nd

PRECEDING YEAR
(

)

(

QUOTA REQUESTED

CURRENT YEAR

)

(

(

)

)

______________grams

______________grams

_________________grams

1ST PRECEDING YEAR

ESTIMATE
FOR CURRENT YEAR

ESTIMATE FOR YEAR
FOR WHICH
QUOTA IS REQUESTED

0

0

0

0

0

0

0

0

0

0

0

0

______________grams
2ND PRECEDING YEAR

12. PRODUCTION DATA

1st PRECEDING YEAR

I. INVENTORY AS OF DEC. 31
a. Bulk Controlled Substance or List I Chemical . . . . . .
b. In-process material . . . . . . . . . . . . . . . .
c. Contained in FINISHED Dosage Forms
TOTAL (a + b + c) . . . . . . . . . . . . .
II. DISPOSITION (SALE ) / UTILIZATION
a. Domestic . . . . . . . . . . . . . . . . . . . . . . . .
b. Exports . . . . . . . . . . . . . . . . . . . . . . . . .
TOTAL (a + b) . . . . . . . . . . . . . . . .
III. ACQUISITION / PRODUCTION
a. Domestic Sources . . . . . . . . . . . . . . . . .
b. Importation . . . . . . . . . . . . . . . . . . . . . . .
TOTAL (a + b) . . . . . . . . . . . . . . .

13. IF THE PURPOSE IS TO MANUFACTURE ANOTHER SUBSTANCE(S), FURNISH THE FOLLOWING INFORMATION:

NAME OF NEW SUBSTANCE

DEA
CHEMICAL
CODE
NUMBER

AMOUNT USED FOR THIS PURPOSE
2ND PRECEDING YEAR

1ST PRECEDING YEAR

% YIELD
(Historical)

CURRENT YEAR

14. IF THE PURPOSE IS TO MANUFACTURE THE BASIC CLASS OR LIST I CHEMCIAL INTO DOSAGE FORMS, FURNISH THE FOLOWING INFORMATION:
NAME OF DOSAGE
FORM
(include product form,
i.e., tablets, patches,
etc. and strengths)

AUTHORITY
TO MARKET
THIS
PRODUCT

SIGNATURE OF APPLICANT

DEA FORM 250

(4/30/2016)

SCHEDULE /
LIST

AMOUNT USED FOR THIS PURPOSE
2ND PRECEDING YEAR

1ST PRECEDING YEAR

ESTIMATE FOR
CURRENT YEAR

PRINT or TYPE NAME and TITLE of SIGNER

ALL PREVIOUS EDITIONS ARE OBSOLETE.

RESET FORM

PRINT FORM

ESTIMATE FOR YEAR
QUOTA IS REQUESTED

DATE